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I LIBRARY OF CONGRESS, 



; UNITED STATES OF AMERICA..! 



LECTURES ON FEVER, 



DELIVERED IN 



THE MEMPHIS MEDICAL COLLEGE, 



18 5 3-6 . 



BY 

A. P. MERRILL, M.D., 

PROFESSOR OF THE PRINCIPLES AND PRACTICE OF MEDICINE. 



NEW-YORK: 
HARPER & BROTHERS, PUBLISHERS, 

FRANKLIN SQUARE. 

1865. 



Entered, according to Act of Congress, in the year 1805, l»y 

A. P. MERRILL, M.D., 

in the Clerk's Office of the District Court of the United State", for the Southern 
District of New-York. 



LECTURES ON FEVER, 



LECTUEE I . 



FEVER. 



We are now to enter upon the consideration of one 
of the most difficult subjects of our profession — fever. 
It is difficult, not because much cannot be said and 
written upon it, but because, rather, of the much 
which has already been said and written, to such lit- 
tle purpose. The subject is difficult, too, because of 
the discrepancy in the views and opinions of authors, 
the number of discordant and contradictory hypoth- 
eses which have been put forth, and the little that 
can be relied upon in all of them which is incontro- 
vertibly true. This, the most common of all the dis- 
eases which afflict mankind, has engaged the atten- 
tion of numerous able and distinguished writers, from 
the time of Hippocrates to the present, and yet it 
must be acknowledged, that there are few material 
points, in reference either to its etiology or path- 
ology, which can now be considered as settled and 



4 Lectures on Fever. 

determined beyond further controversy. And this 
remark is scarcely less applicable to the subject of 
treatment. Physicians have always differed in re- 
gard to this, and they continue to differ. Even in 
the same district of country, and in the same town, 
however small, various and conflicting methods of 
cure are followed and relied upon, although there is 
great uniformity in the character of the prevailing 
fever. Indeed, this uniformity in the pathology of 
the "disease seems to be almost the only uniformity 
which we meet with in regard to the whole subject, 
and even this is observed without being understood. 
Yet the laws of nature in this regard, as in other 
matters, are, without doubt, invariable and unchange- 
able. Could we but learn and comprehend the great 
mass of valuable and immutable truth, in connection 
with this common disease, it would lead to more suc- 
cessful treatment, and be of great and important serv- 
ice to suffering humanity, producing, indeed, an in- 
crease in the average duration of human life. 

For the want of this certain knowledge, it becomes 
difficult for the student of medicine to arrive at just 
conclusions, in reference not only to the true theory, 
but the proper treatment of fever. And it is scarcely 
less difficult for the teacher, in the mass of discordant 
materials by which he is surrounded, to seleqt and 
arrange those portions only which are best suited to 
the elucidation and proper understanding of the sub- 



Lectures on Fever. 5 

ject, and so to prepare a series of consistent and intel- 
ligible lectures, whicli can be listened to with interest 
and made useful in practice. In the present effort, a 
free use will be made of the observations and teach- 
ings of others, without adhering to the views of any 
one author, while the class will receive, as it has a 
right to expect, such results of my own long experi- 
ence in the treatment of southern fevers as may 
promise to be useful. 

Fever is probably the only diseased condition which 
invariably implicates the entire system. Whenever 
and under whatever circumstances it may happen to 
exist, it exercises, in all cases, a palpable influence over 
the whole body — over the solids and the fluids, the 
muscular fibres, membranes, digestive organs, brain, 
and the vascular, nervous, and glandular systems. 
Wherever the blood circulates, or the nerves are dis- 
tributed, there are signs of the diseased condition, as 
there are also, we have reason to believe, in all the 
vital fluids of the body. In general, fever is accom- 
panied by an increase of animal heat, but not always, 
and quite as commonly, the inceptive stage is that of 
chill, but even this is not a uniform concomitant. 

Of the cause of fever, it is quite safe to say we 
know nothing ; and I need not trouble you, therefore, 
with an account of the various hypotheses on that 
subject. In regard to exterior influences, no one 
cause has been suggested, so far as I am aware, which 



6 Lectures on Fever. 

may not exist, under some -circumstances, without 
producing fever in those exposed to its influence ; and 
probably the converse of this proposition is equally 
true — fever may occur without our being able to as- 
sign it to any cause which has ever been suggested. 
Crowded apartments, want of ventilation and cleanli- 
ness, unwholesome food, chemical decomposition, ex- 
posure to inclement weather, etc., are all reputed 
causes, which not only are found existing in many 
places without producing fever, but which have some- 
times appeared to afford protection against fever, 
while the most fatal forms of fever have often pre- 
vailed as epidemics where none of the commonly 
alleged causes could be discovered. 

It has been contended that fever is always depend- 
ent upon some local inflammation or irritation, as a 
necessary condition precedent and real cause, and 
that it never exists as a primary form of disease ; in 
other words, that fever is always symptomatic of some 
other morbid affection. But this view does not ap- 
pear to be sustained, either by observation or by post- 
mortem appearances ; for fever is often known to ex- 
ist without any previous signs of local disease ; and 
autopsic proofs of inflammation appear in cases which 
have shown no signs of general febrile action. If a 
considerable degree of local inflammation may exist, 
therefore, without any signs of general fever, and if a 
considerable amount of general fever may exist, with- 



Lectures on Fever. 7 

out signs of local inflammation, we may safely infer 
that there is no necessary connection between the two, 
and that either one may exist without causing or 
being caused by the other. 

The humoral pathology, with certain variations 
and modifications, w r as the popular hypothesis for 
many ages, from the era of Hippocrates. The preva- 
lent notion was, that febrile heat was, in some way, 
owing to changes taking place in the constituents ol 
the blood, the bile, and the phlegm ; and as medical 
men had then no knowledge of the circulation, these 
fluids were strangely confounded and blended togeth- 
er. The doctrine of fermentation and putrescence 
was the natural result of this exclusive reference to 
the fluids ; and when the circulation of the blood was 
afterward discovered, it required no great stretch of 
the imagination to conceive that the main effort of 
nature in fever was, by the movement of this fluid 
through the arteries and veins, to expel certain mor- 
bid humors from the body. Chemical combinations 
were also supposed to be taking place in all the fluids ; 
and Boerhaave supposed that the blood became so 
thickened in fever, that it could not circulate freely 
in the capillary vessels, and that this was the cause of 
the cold stage and the subsequent reaction, in some 
way not explained. 

Fever was, for a long time, considered not so much 
a disease, as an effort of nature to rid the system of 



8 Lectures on Fever. 

some morbid product — some diseased quality or ad- 
mixture of the blood — the existence of which could 
not, of course, be proved. The humoral pathology, 
therefore, was a mere hypothesis, founded wholly 
upon an assumption of facts, and if there was some 
truth in it, as is now contended by many, it was 
wholly accidental. In the then state of physiological 
and chemical knowledge, and without the means of 
analyzing the blood and other fluids of the body, there 
w T as no possibility of constructing a reliable or even 
an intelligible theory of fever, upon any scheme of 
humoralism ; nor have modern investigations afforded 
us much assistance in this respect, in the establish- 
ment of undoubted facts. But the hypothesis has 
had an influence, both in ancient and modern times, 
in favor of a negative or expectant treatment of fever, 
relying mainly upon the powers of nature to effect a 
cure. 

It is remarkable, that among all the able men who 
wrote upon fever, the solids of the body should not 
have been mentioned as having any agency in its 
phenomena, until the hypothesis of disordered inner- 
vation was called into view by Stahl and Hoffman, 
who substituted a spasm of the capillary vessels for 
the thickened blood and the error loci of Boerhaave ; 
and this idea seems to have been seized upon by Cul- 
len, without considering that there was no more 
proof of the existence of spasm than of a diseased 



Lectures cm Fever. 9 

condition of the blood ; but it was even nfore com- 
mon then than now, to construct hypotheses upon as- 
sumed data. Cullen taught, that the first effect pro- 
duced upon the system by the cause of fever is, to 
establish a diminution of cerebral and nervous energy, 
constituting an early stage of collapse, or depression 
below the standard of health. It was supposed, and 
this without any good reason, that this condition of 
nervous debility caused the spasm of the capillary 
vessels, and a consequent reduction of their calibres. 
The subsequent reaction, it was contended, relieved 
this condition of spasm and constriction, causing re- 
laxation and sweating, and also the excretion of mor- 
bid matter ; for this idea was adhered to by authors 
on fever long after the humoral pathology was dis- 
carded, if not even to the present time. 

Cullen evidently deemed it incumbent on him as 
a prominent teacher in medicine, to concoct and pro- 
mulgate a theory, or rather hypothesis, of fever, as so 
many others had done before him, and, like them, not 
having the facts or the knowledge of facts necessary 
for the purpose, he did not hesitate to follow their 
examples, and supply the deficiency by copious 
drafts upon a fertile imagination. It is of little con- 
sequence, perhaps, that he taught the doctrine of 
spasm ; but that of debility, connected therewith, has 
been productive of much mischief. He committed 
the strange mistake of confounding the temporary 
1* 



10 Lectures on Fever. 

nervous depression which precedes the febrile exacer- 
bation, with actual constitutional debility, and thus 
inaugurated a system of excitant treatment, which 
has been and even now is very destructive of human 
life. The gastric disturbance which commonly at- 
tends upon fever he, quite as strangely, considered as 
evidence of an u atony subsisting in the extreme vessels 
of the body ;" and this assumed existence of atony, con- 
nected with a state of tonic spasm in the same tissues, 
lent further support to the excitant treatment. And 
this is just the w x ay in which the most absurd medical 
hypotheses have been formed by men of learning, 
whose influence has been sufficient to carry the whole 
medical profession, in their train, spreading evil and 
mischief broadcast over the world. 

Brown next appeared, promulgating, in a spirit of 
rivalry, an hypothesis even more extraordinary still. 
This was somewhat more ingenious and intelligible, 
perhaps, but not more true and enduring than the 
preceding one. While it differed so essentially from 
that of Cullen in all other respects, it unfortunately 
contributed to sustain the fatal doctrine of debility 
and the excitant treatment of fever. This hypoth- 
esis, so captivating, and, for a while, so popular, was 
founded upon the supposed relations existing between 
excitability and excitement. It proposed to consol- 
idate all disease into two simple classes, sthenic and 
asthenic, to be treated respectively by depletion and 



Lectures on Fewer. 11 

stimulation. He succeeded, for a time, in winning 
over from Cullen many of his disciples, white he un- 
wittingly propagated his very worst error — that of 
constitutional debility, which has slain its thousands. 

Darwin, with more genius and imagination than 
either Cullen or Brown, attempted an important im- 
provement upon the brunonian hypothesis. Consid- 
ering the brain to be the chief source of sensorial 
power — a mere secretion of that organ — he taught 
that it might be exhausted of its energy by various 
modes of excitation, and as certainly replenished by 
nutrition and rest. The old idea of a torpor of the 
capillary vessels was inculcated by him, which torpor 
was supposed to lead to an accumulation of sensorial 
power, and consequent reaction. 

Neither of these popular hypotheses of fever, which 
has each in its turn carried captive the profession in 
both Europe and America, makes fever dependent 
in any degree upon the influence of local inflamma- 
tion ; but a host of hypothetic authors have since 
appeared, insisting upon the truth of this doctrine, 
and making fever a symptomatic affection. Local 
lesions have been found in the brain and other or- 
gans, post mortem, and the fever causing death has 
been attributed to the agency of such lesions, al- 
though no signs of their existence may have appeared 
anterior to the febrile development. Stahl, Clutter- 
buck, and others, designated the brain as the seat 



12 Lectures on Fever. 

and source of all the mischief ; but Broussais and 
his followers professed to have discovered the error of 
these cerebralists, and, for no better reasons than 
those which guided their predecessors, placed the 
local cause of fever uniformly in the mucous mem- 
brane of the digestive organs. One party professes 
to. find this cause in an overworked brain ; the other 
in an overworked stomach ; and both illustrate their 
positions by autopsic inspections. 

The hypothesis of the ventralists, like that of the 
cerebralists, met with pretty general acceptance ; and 
the more, no doubt, for its being made the basis of 
what its author chooses to call " the physiological 
system of medicine ;" but why it is more physiologi- 
cal to locate the cause of fever in the stomach than 
in the brain, we are not informed. Two reasons are 
urged, however, why this system should be preferred 
to the other. One is, that more or less traces of in- 
flammation are to be seen, with some exceptions, in 
the mucous tissues of fatal cases ; and the other, 
that the treatment founded upon this pathology is 
successful. But the same reasons, substantially, have 
been given in support of all other systems. As in 
the humoral pathology, to which this appears to be a 
legitimate sequel, the vis medieatrix naturce is still 
the divinity to be invoked. We are required to re- 
move all causes of irritation from the membranous 
contact, and trust the rest to nature. 



Lectures on Fever. 13 

Louis has amended the " physiological system," by 
discovering, what had strangely escaped the scrutiny 
of Broussais, that the local lesion is not in the mu- 
cous membrane, but in Peyer's glands ; and this he 
claims as the introduction of a new system, in the 
following remarkable language : u Observe closely 
these numerous crypts, these glands, which, in their 
normal state, are almost imperceptible, which are 
usually called the glands of Peyer ; these infinitely mi- 
nute organs, which, notwithstanding their agglomer- 
ation, have so long remained unperceived, and to 
which anatomists were at a loss to attribute any func- 
tion, except the secretion of a little mucus ; these or- 
gans are destined hereafter to play a grand role^ nay, 
the first role in pathology. They have far greater 
importance pathologically than the liver, the spleen, 
the lungs, the encephalon itself; for I have discovered 
that they are .the seat of all those numerous and 
varied diseases, so fatal to the human race, so dis- 
couraging to physicians, which occur in epidemics 
under so many forms, which have exercised the saga- 
city of the greatest geniuses from Hij>pocrates until 
now ; of those diseases, lastly, which have been so 

improperly called primary or essential fevers 

Recollect that there is no such thing as inflammatory 
fever, or bilious, or putrid, or malignant fever : we 
have changed all that ; remember that all these fevers 
are comprised in typhoid fever, inasmuch as they all 



14 Lectures on Fever. 

have, as their common characteristic, a profound and 
specific lesion of the elliptical patches." 

ISTo bolder attempt than this has ever been made to 
build up an original theory or hypothesis ; and yet it 
is scarcely put forth before the discovery is made, that 
the lesion which is here considered so essential to the 
existence of fever, is not a constant concomitant. It 
can, indeed, only be determined to exist at all by 
post-mortem examination. A single exception, you 
will perceive, is fatal to the whole system ; and there 
is now no reason to doubt that fever very often exists 
without either inflammation of the intestinal mucous 
tissues, or of the glands of Peyer. Neither can, 
therefore, be considered an essential cause or condi- 
tion. It seems, moreover, more than probable that 
both these lesions, when they exist at all, are the 
effects of fever. These theories of the French school, 
therefore, which have been so confidently announced, 
and so trustingly received, present no stronger claims 
upon our confidence than those which preceded them ; 
nor do they promise more durability. Indeed, one 
can hardly examine the various theories of fever, 
which have up to the era of Louis been promulgated, 
and contemplate the errors in practice which have re- 
sulted from them, without acknowledging the truth 
of the maxim of Cayol, one of the critics of Louis : 
" Systems in medicine are idols, to which hximan 
victims are sacrificed" 



Lectures OTi lu r, r. 15 

The student of medicine is expected to inform him- 
self in regard to the character of the prominent hy- 
potheses which have been published; but the natural 
effect upon the minds of those who are in pursuit of 
truth is, to impress them with the uncertainty which 
must ever attend upon the most able and ingenious, 
founded in any degree upon assumed data. It is be- 
cause of this unsubstantial basis that so large a num- 
ber have been promulgated upon this subject. Each 
has had its adherents, who were ready to subscribe to 
every assumption, and every dogma ; and the dura- 
tion of one seems to have been limited only by the 
appearance of another to take its place. As each in 
its turn has occupied the attention, and secured the 
confidence of the profession, it has required consider- 
able moral courage to question its soundness ; but 
you may safely consider, that what has been written 
in explanation of fever hitherto is merely hypothetic; 
and you will do well to believe, that theories in med- 
icine, as in other branches of science, must always be 
founded upon well-established facts, without which 
they are not entitled to confidence. 

Whatever may have been said of fever as proceed- 
ing from the influence of local irritation, it is not now 
to be doubted that whenever it exists, it involves the 
whole system in its abnormal action. In general, if 
not always, it is a mild disease in its early stages, in- 
somuch that it is not an easy matter, in many cases. 



16 Lectures on Fever. 

to determine the actual period of its beginning. In 
its slow and gradual progress to greater and greater 
intensity, it affects the system somewhat unequally, 
in some parts more than in others, according to the 
degree of susceptibility of different organs and tissues ; 
until, finally, when the disease becomes developed, and 
symptoms of serious import arise, some one organ or 
tissue is found to be more particularly implicated 
than the rest, causing much suffering from the local 
as well as from the general disease; and it is just at 
this period that the advice of the physician is most 
likely to be required. He finds the patient suffering 
with fever, the attack being generally referred to that 
period in its progress in which a distinct chill, or 
other painful symptom, occurred. But if diligent in- 
quiry be made, it will be found that the first signs of 
disease appeared at an earlier date, often several days, 
and sometimes even weeks, before the true character 
of the ailment was discovered. 

I shall have occasion, probably, to refer to this 
matter again, but I mention it now to enable you to 
account, in some measure, for the discrepancy in the 
views of those who have thought themselves called 
upon to construct systems in medicine ; and also to 
deprecate the fact, that this slow and insidious char- 
acter of fever, in its approaches, has hitherto been too 
little noticed by authors. I shall attempt to show 



Lectures on Fever. 17 

you, too, as we go on with the course, that fever, in 
all its various forms and grades, is, in its inceptive 
stage, a mild and tractable disease, even when pre- 
vailing as a fatal epidemic. 

In thus condemning the views of so many distin- 
guished writers on fever, all of whose ingeniously 
constructed systems have proved to be only epheme- 
ral, it is not my intention to propose one of my own. 
I have none to offer. If you ask me what I consider 
to be the true cause and pathology of fever, I must 
express to you my belief that these yet remain to be 
discovered ; and when we consider what have been 
the labors and researches of the ablest men in our 
profession, it seems quite strange that greater discov- 
eries have not been made. So it is, however, and we 
must look to the future for instruction upon these 
subjects, without much dependence upon the past. 
Xew means and appliances of investigation are com- 
ing constantly into use, and possibly the facilities to 
be afforded for chemical analysis, and for microscopic 
observation, together with a more thorough acquaint- 
ance with the workings of the nervous system, may 
ere long reveal what has hitherto been hid from hu- 
man scrutiny. At the present time; we must pa- 
tiently content ourselves with the rules adopted by 
philosophers in reference to the imponderables, known 
only from their effects. The time is past, I judge, 



18 Lectures on Fever. 

when mere hypothesis, however ingeniously con- 
structed, can secure the support of our profession. 
The age in which we live seeks for truth, and ac- 
knowledges the necessity of a substantial foundation 
in ascertained facts, for all theories of disease. 



LECTUEE II. 

FEVER. 

Fever is known sometimes to be symptomatic oi 
some local affection, as when produced by a wound, or 
injury of some kind, causing active inflammation, and 
affecting the whole system by sympathy. Some have 
concluded, therefore, that all fever is necessarily symp- 
tomatic. Indeed, so common has been this view, that 
some authors have been unable to conceive how fever 
can otherwise exist. They are unwilling to acknow- 
ledge that fever is, or can be, an essential disease, or a 
disease sai generis / and, for some reason unexplained 
and unexplainable, they prefer to consider it a mere 
symptom of some other disease. Hence the extraor- 
dinary efforts made to discover some one lesion, as the 
invariable cause of fever. This, as I have already 
shown you, is the high ambition of certain celebrities 
of the French school of medicine ; but they are as yet 
unable to agree upon the particular lesion necessary, 
or even to designate any one which invariably exists, 
either as a condition precedent or concomitant. 

But, however strongly inclined to respect high au- 



20 Lectures on Fever. 

thority in these matters, we are forced by observation 
and experience to believe, that fever may, and often 
does, exist as a condition precedent, and that these 
local derangements and complications just as often 
follow attacks of fever as consequences. They are 
dependent for their locality in these cases, probably, 
upon epidemic influence, or upon some peculiar sus- 
ceptibility of the organ or tissue affected. In win- 
ter, the action of the cold air, and sudden transitions 
of temperature upon the lungs, seem to predispose 
these organs to the disordering influences of febrile 
action, and we have pneumonic fever prevailing, to the 
almost entire exclusion of other forms. At other sea- 
sons, the brain, stomach, intestines, liver, etc., become 
the more susceptible and impressionable organs, and 
hence the more common complications — phrenitis, gas- 
tritis, enteritis, hepatitis, etc. ; and the fever, after such 
development occurs, must be treated with special refer- 
ence to the local lesion, wherever it may appear. The 
local lesion once begun, and sustained by the retroac- 
tive influence of the fever, may proceed to an extent 
dangerous to life. Reacting upon the whole system 
as a local irritation from any other cause, its tendency 
is to prolong, and in some respects to change the char- 
acter of the fever to which it owed its origin. The 
suffering and danger resulting will depend upon the 
intensity of the fever, its duration, and especially 
upon the organ or tissue principally affected. The 



Lectures on Fever. 21 

difference in the intensity and danger of cases may 
approximate very nearly to the difference existing 
between such local affections appearing as primary 
diseases. Many of the symptoms are, indeed, the 
same as in local inflammations proceeding from other 
causes, and the indications of cure are similar. 

But while contending for these local lesions as the 
common effects of fever, we must be careful not to 
ignore their existence as causes ; although it is true 
that they rarely occur as such in this climate. Cere- 
britis, gastritis, enteritis, pneumonitis, etc., are rare 
diseases in this climate, except as local lesions of pre- 
vailing fever ; but whenever they do occur from other 
causes, symptomatic fever may or may not attend 
upon them, being caused, no doubt, when it does ap- 
pear, by the constitutional irritation resulting from 
the local disease. In such case, the local lesion is, 
of course, the primary, and the fever the secondary 
affection, standing in relation to each other as cause 
and effect. Now, all these things will appear to you 
as little more than truisms ; and yet it seems to be 
necessary to state them, on account of the credit 
which is so largely given to the physiological doctrines, 
or the exclusive symptomatic system of modern writ- 
ers. In the treatment of fever, it is of great import- 
ance to exercise a sound discrimination in regard to 
this matter of cause and effect, lest we may sacrifice 
human life by vain efforts to relieve a local affection, 



22 Lectures on Jt^ever. 

without due regard to the cause producing it. As 
well might w r e attempt the cure of ophthalmia, while 
the grain of sand which caused it is still in the eye. 

That all febrile excitement consists in morbid re- 
action, from a state of nervous depression, arising 
from some unknown cause, in idiopathic fever ; and 
that, in all other cases, febrile action is caused by lo- 
cal irritation, affecting the whole system by sympathy 
with a particular part, will, I think, be denied by 
very few physicians in the South, whatever may be 
the opinions entertained elsewhere. And I judge from 
the writings of distinguished foreigners that the ef- 
fects produced upon local organs and tissues by idio- 
pathic fever here, are very much the same as in Eu- 
rope. Thus we have, in winter, periodic fever, aris- 
ing from some unknown cause, which, like the ty- 
phus and typhoid fevers of more northern latitudes 
as described by Stokes and others, almost constantly 
produce congestions and inflammations in the thora- 
cic viscera ; and with us, on this account, they are 
denominated pneumonia, pneumonic fever, etc , pneu- 
monia in any other form being a rare disease here. 
So, also, in summer and autumn, for reasons not yet 
understood, the congestions and inflammations from 
the same cause appear mostly in the abdominal vis- 
cera, and our nomenclature is changed accordingly. 
This is said, also, to be the case in foreign countries, 
especially in Southern Europe. The fevers of Spain, 



Lecture* on Sever. 23 

Italy, and the South of France, as described by med- 
ical writers, are the same as in the Southern States, 
even to the occasional appearance of gastric or yel- 
low fever, sporadic or epidemic ; and, of course, they 
are attributable to the same cause. In -Great Brit- 
ain and Ireland there has been some dispute as to 
the general existence of the periodic feature in con- 
nection with fever ; but there are physicians in those 
islands, not a few, who acknowledge its prevalence, 
and who adopt the antiperioclic treatment. Especial- 
ly is this true of those physicians who have resided 
in southern colonies, and who haye thus, from their 
own observations, become good judges of this matter. 
It seems to me not improbable that a difference of 
opinion may arise from the fact, that the different 
stages of fever in those northern countries are less 
distinctly developed ; and it may be that the febrile 
lesions appear at an earlier period, reacting upon the 
system by constitutional irritation, and thus exhibit- 
ing early signs of symptomatic fever, as an effect of 
this local disease. In the [Northern States there is 
the same difference of opinion. The physicians of 
Philadelphia, who have given us pretty much all that 
is valuable in medical authorship in America, ac- 
knowledge the periodic character of their fevers, 
particularly those of summer and autumn ; and they 
employ the bark and its salts scarcely less freely than 
we do in the South ; while in ]^sew-York and Boston 



24 Lectures on Fever. 

the disposition, we are told, prevails, to ignore the 
prevalence of periodicity, although quinine is pretty- 
freely used in the treatment of fever, but it is given 
as a tonic, and not as an antiperiodic remedy. 

Whenever we attempt to treat of fever, about the 
cause and character of which so little is known, we 
must, to be practical, confine ourselves mainly to the 
various phenomena which the disease presents to our 
observation, from its inception to its close. And noth- 
ing can be more important, in this practical point of 
view, than to determine accurately the relation which 
the constitutional disturbance bears to the local con- 
gestions and inflammations which attend upon it. In 
the pursuit of this inquiry for ages past, authors have 
constantly differed in regard to cause and effect ; some 
contending, as we have seen, that fever is an effect 
and a symptom of some local affection ; and others, 
that it is more commonly a primary and essential dis- 
ease, and an exciting cause of local derangements. 
Divested of the influences of all preconceived hypo- 
theses, this is, in every case of fever, a mere question 
of fact ; and we must look to facts rather than to idle 
and fanciful speculations, if we wish to arrive at cor- 
rect conclusions. Let us therefore consider what facts 
teach us ; many of you have observed them already, 
and you may observe them in your intercourse with 
the sick, daily. 

It often happens in this country that a person, com- 



Lectures on 'Fever. 



20 



ing from a healthy region into one where periodic 
fever is prevailing, begins, in a few clays, to feel some 
degree of indisposition. At first it is slight, tempo- 
rary, and scarcely noticeable; but it increases from 
day to day until developed into a distinct chill ; and 
the occurrence of this chill is the first convincing 
proof he has of the nature of his insidious malady. 
The chill is followed by the hot and sweating stages 
of the febrile paroxysm, perhaps only obscurely de- 
fined, and the subject is, to all appearance, well again. 
The paroxysms return, however, at the regular quo- 
tidian or tertian periods, and become more distinct 
and violent at each successive repetition. After a 
while, signs of some particular local disorder begin 
to appear, and this local affection, constantly increas- 
ing in violence, becomes, in due course of time, the 
most troublesome feature in the disease, and the prin- 
cipal obstacle in the way of treatment. Sometimes, 
indeed, if relief be long delayed, this local disease 
becomes an obstinate chronic affection, which contin- 
ues to afflict the patient long after the fever has been 
arrested. Xow, to contend, in such a case, that the 
local disease was the primary, and the fever a second- 
ary affection, would be to acknowledge, for the sake 
of sustaining a theory, that such local lesion may ex- 
ist, and to an extent to disorder the whole system by 
sympathy, without our being able to detect even its 
2 



26 Lectures on Fever. 

existence ; and this no physician would like to ac- 
knowledge. 

Again, a man in full health arrives at New-Orleans 
from beyond the seas, while the yellow fever is epide- 
mic in that city ; he sleeps there a single night, and 
then passes on up to Memphis. Perhaps on the third 
or fourth day of his voyage he complains of nervous 
depression, headache, and loss of appetite. These 
symptoms recur and increase from day to day, with 
alternations of excitement, both bodily and mental, 
until the eighth or ninth day, when he first experi- 
ences a distinct, but moderate chill. A febrile exa- 
cerbation succeeds, slight and seemingly unimportant 
at first, but becoming more and more violent every 
hour, with constantly increasing pain in the head, 
back, and limbs, a short morning remission, quickly 
followed by a still more violent exacerbation, until, 
perhaps, on the third day from the chill, there is a 
sudden abatement of all these painful symptoms, and 
malignant gastritis appears, with all the appalling 
concomitants of this fatal disease. In two davs more 
the life of the patient is extinguished, with copious 
ejections of black vomit. 

Now, this is a case of yellow fever, contracted, as 
is not uncommon, by sleeping a night within the 
sphere of its epidemic influence. The gastritis, which 
appears as a prominent symptom at so late a period 
of the disease, is, according to all writers on the sub- 



Lectures on Fever. 27 

ject, the characteristic lesion, and without which yel- 
low fever does not exist. Is it, in such a case as I have 
supposed, the primary affection and cause of the 
fever ? Nothing could be more improbable ; for this 
formidable disease does not exist for several days 
without making its presence known. The suffering 
in the head, back, and limbs, in this case, is the le- 
gitimate effect of fever from any cause whatever, and 
with these symptoms alone, the patient may often be 
cured by very simple remedial measures. But when, 
from epidemic influence, or some other cause not un- 
derstood, the stomach becomes involved, and the phy- 
sician has to contend with malignant gastritis com- 
plicating remittent fever, the disease is beyond the 
ordinary resources of the profession, and recoveries 
are only the exceptional cases. 

We have seen that some authors have made fever 
to be dependent upon conjectural changes in the con- 
stitution of the blood and other vital fluids, and some 
upon disordered action of the solids. Others, again, 
have contended that the brain and nervous systems 
should be primarily influenced by the exciting cause. 
To these hypotheses have been superadded others, 
concerning pathological conditions in some degree in- 
cidental to febrile action, having relation to the ex- 
istence of spasm, constriction, excitability, debility, 
local irritation or inflammation, follicular and mem- 
branous disorder, etc. But all these appear to have 



28 Lectures on Fever. 

been founded only upon assumed facts, or deduced 
from deceptive post-mortem appearances. It has not 
been proved, in a single case of fever, that these 
changes in the constitution of the blood, the condition 
of the solids, the action of the brain and nervous sys- 
tem, the spasm and constriction of the capillary ves- 
sels — if any such there be — the existence of debility, 
excitability, local irritation, or follicular and mem- 
branous inflammation, one or all, have always existed 
as a condition precedent in idiopathic fever. ~No one 
of these conditions has been proved necessary to the 
existence of fever, nor is any one of them certain to 
produce fever, when it occurs from any other cause 
than fever itself. If, then, fever may exist without 
any of these conditions, and each and all the condi- 
tions exist without fever, we may safely conclude that 
they are not the proper causes of fever or in any way 
essential to its existence. 

Notwithstanding the general belief, in times past, 
that a final quietus had been given to the humoral 
pathology, a strong disposition has lately been shown 
to revive it, or at least to acknowledge the primary 
disorder of the blood as the cause of fever. Physici- 
ans have, indeed, ventured to proclaim fever a blood 
disease, professing to have ascertained, that even the 
graver forms, so fatal to northern men in hot clim- 
ates, are due to a deficiency of saline materials in the 
blood. This deficiency is supposed to be caused by 



Lectures on Fever. 29 

the entrance of the cause of fever into the blood-ves- 
sels, corrupting their contents by chemical action. It 
has been shown, too, we are told, that changes in the 
blood, similar to those accompanying fever, are pro- 
duced, by injecting certain putrid matter into the 
veins, causing fermentation of the blood, even while 
in performance of its vital functions. Strange to 
say, it has been inferred, from experiments of this 
kind, that all fever is dependent upon this process of 
decomposition of living fluids, while circulating in 
the living body. 

Notwithstanding the inconsistences involved in all 
these experiments and observations, there is much 
plausibility in this modern phase of humoralism ; but 
not more, certainly, than in various other hypotheses 
to which I have referred. The great difficulty with 
all of them is, they are not proved to be true. They 
are not, any of them, founded upon established data, 
and we must consider them, therefore, to be mere 
hypotheses, the ingenious conjectures merely of learn- 
ed men. The brain and the bowels have been found 
diseased, upon examination of the bodies of fever 
patients after death, and it was inferred that first 
one and then the other must be the exciting cause of 
the disease. Xow it is said to have been ascertained, 
that the blood is uniformly disordered in fever, and 
with this important advantage to the new doctrine : 
we are enabled to determine its condition in the life- 



30 Lectures mi Fever. 

time of the patient, and we are taught to infer from 
this, that it is the cause of fever. But it can, with 
just as much propriety, be said of the blood as of the 
brain and bowels, that although found to be diseased 
in fever, it has not been shown to be a condition pre- 
cedent, and, therefore, it is just as likely to be an 
effect as a cause. Indeed, it is contended by some 
physiologists, that similar changes are produced in 
the blood by active exercise alone, or by whatever 
has the effect to accelerate, for any length of time, 
the circulation of the blood. Hence it may be in- 
ferred, that febrile excitement, even in its early stages, 
may cause this disease of the blood. 

But when we contend that the cause of fever acts 
upon the system very slowly, producing, for several 
days, little perceptible change, and that weeks and 
even months may elapse before the febrile paroxysm 
is distinctly developed, it may be contended that 
these slow and gradual changes are dependent upon 
the fact, that the exciting cause has found a lodg- 
ment in the blood, which undergoes a gradual dete- 
rioration, impairing nervous power, and disordering 
the functions by slow degrees. This is a plausible 
conjecture, but it has no well-proved fact to sustain 
it. Nor has the doctrine of the primary disorder of 
the blood the negative evidence in its support which 
has been claimed, for we can have no more difficulty 
in attributing these slow and gradual changes to a 



Lectures on Fever. 31 

direct influence over the brain and nerves, than over 
the blood. Indeed, we have better reasons for believ- 
ing, both from analogy and experiment, that the 
blood becomes diseased in such cases only through 
the agency of disordered innervation. I do not con- 
sider that we have better proof, therefore, that fever 
is essentially a blood disease, than we have that it is 
essentially and primarily a nervous disease. 

Vitality is acknowledged to be powerfully antag- 
onistic to chemical decomposition. In some of its 
forms, its resists successfully even the digestive pow- 
ers of the stomach. Now the blood, while circulat- 
ing in the body, is undoubtedly a vital fluid, and it 
is only when drawn from the arteries and veins, and 
exposed to the air, that it loses its vitality and un- 
dergoes decomposition. Probably it is not less vital- 
ized than the substance of the brain and nerves, or 
the lining membrane of the stomach and bowels. It 
is, moreover, just as much under the influence of 
nervous power as any organ or tissue of the body, 
not being capable of undergoing the important pro- 
cess of arterialization, or of performing the offices of 
nutrition and the generation of animal heat, without 
this agency. The blood, we may suppose, therefore, 
to be just as likely to become the subject of second- 
ary disease, the subject of local lesion, so to speak, 
as either the brain or the stomach and bowels ; and 
while it has not been proved that it becomes diseased 



32 Lectures on Fever, 

at any time anterior to the accession of fever, we are 
justified in the conclusion, that the changes which 
are found to have taken place in the constitution of 
the blood are, like other lesions of fever, of a second- 
ary character, and caused by febrile excitement, and 
that these changes in the blood are not, as has been 
supposed by some, the exciting cause of fever. 

The tendency recently shown to return to the sup- 
port of certain features in the old humoral path- 
ology, finds no small encouragement in the modern 
teachings of a non-vital physiology. This lends en- 
couragement to the doctrine of blood fermentation, 
or the possibility of a chemical decomposition of the 
blood, even while circulating in the arteries and 
veins, and performing its legitimate functions in the 
living body. Such changes once acknowledged to be 
possible, we can hardly refuse to concede the chem- 
ical dissolution of the solids of the body also ; and 
then we must hold ourselves liable, at all times, to 
sudden decomposition under those influences which 
favor the fermentation process in dead animal matter 
everywhere. Whether there be danger of carrying 
these new doctrines thus far, I do not pretend to 
know ; but when new principles are proposed for our 
acceptance and belief, it is always fair to test them by 
extreme views. 

After all that has been written about fever, from 
the earliest times until now, Ave are forced to the 



Lectures on Fever. 33 

conclusion, that it is known only from its obvious 
phenomena. The ingenious disquisitions of able men 
have done little to enlighten us in regard to it. Of 
the nature of its primary cause, nothing has been 
yet discovered. Its pathology, in all its forms and 
phases, is involved in obscurity. It may be epidemic 
over a large district of country, in a city, or among 
a single household, and it often occurs in only a few 
sporadic cases here and there, seemingly quite at 
random, while the great majority of population es- 
cape it altogether. In regard to the character of the 
disease, we only know that it comes on with wonder- 
ful uniformity, in spite of the varied conditions at- 
tendant upon it ; that all parts of the body are in- 
volved in the morbid action from the beginning, and 
during the whole course of the disease ; that there is 
nervous depression and chilliness, followed by general 
reaction of a morbid character, and not such as fol- 
lows nervous depression from other causes ; and there 
are remissions and exacerbations, according to a mys- 
terious law of the animal economy, which has not yet 
been explained. Local lesions follow, as the effects 
of this febrile movement, sometimes in one organ or 
tissue, and sometimes in another, and these become 
serious almost in the direct ratio of the violence and 
duration of the constitutional disease. And we know 
that fever results in recovery or in death, under the 
influence of many conditions having reference to the 



34 Lectures on Fever. 

constitution and habits of the patient, the character 
of the prevailing epidemic, the seat and violence of 
the local lesions, the frequency of the paroxysms, and 
the treatment adopted. 

Fever in this country, if not in all countries, is the 
most common form of disease, and in the practice of 
your profession you will be called on to treat it more 
than all other diseases. Sometimes it is mild and 
almost harmless, at others, severe, complicate, and 
fatal. Sometimes it is well developed, distinct and 
well defined; at others, obscure, masked, and not 
easily detected. JSTot unfrequently the utmost efforts 
of medical skill are expended for the relief of a febrile 
lesion, while the fever producing it is unnoticed and 
neglected. Nothing is more important, therefore, 
than that you should study the subject with the ut- 
most care ; and in doing this, I advise you to divest 
your minds of all prejudice and all preconceived 
opinions. The finely-wrought hypotheses to which I 
have so often referred, will be of no service to you ; 
and from the teachings of pathologists you will de- 
rive little advantage, except as they relate to local 
lesions, which, in general, are to be treated as the 
same lesions are when they appear as primary affec- 
tions arising from local causes. These are irritations 
and inflammations of particular organs and tissues, 
the pathology of which is involved in considerable 



Lecture* an Fever. 35 

obscurity, but the diagnosis is often plain and unmis- 
takable. 

I advise you, finally, to keep constantly in view 
the judicious observations of Fordyee, who says, that 
fever is a disease which no knowledge of the struc- 
ture of the human body, no knowledge of the prop- 
erties of the fluids, no knowledge of the action of the 
moving parts, could give the smallest ground to sup- 
pose ever existed. It affects the whole system, the 
head, the trunk, and the extremities ; it affects the 
circulation, the absorption, and the nervous system : 
it affects the skin, the muscular fibres, and the mem- 
branes ; it affects the body and the mind. It is. there- 
fore, emphatically a constitutional disease, and it is 
not necessarily dependent for its existence upon any 
local disease, although the prolific source of so many 
forms of local disease, affecting both solids and fluids. 



LECTUKE III. 

INTERMITTENT FEYEE, 

Intermittent fever is the most simple and distinct 
form of periodic fever, and it serves, in a measure, as 
a type of all other forms. Three principal varieties 
are spoken of by authors — the quotidian, the tertian, 
and the quartan — which are terms having reference 
entirely to the type or the duration of the intermis- 
sion, the disease, in all cases, being the same. These 
varieties of form are subject, from some unknown 
cause, to certain irregularities, which have given rise 
to other designations as duplications and triplications 
of these. Other periods of intermission are also men- 
tioned, extending variously to periods of five to twen- 
ty-one days, and even longer. All these types or 
forms are liable to be converted into one another ; 
and when those of the shorter are converted into the 
longer periods of intermission, the danger of a fatal 
termination is supposed to be lessened, and the re- 
verse. If a quartan or a tertian ague be converted 
into a quotidian, it is taken as an indication of in- 
creased severity in the disease ; and when the fever 



Lectures on Fever. 37 

ceases to intermit and becomes remittent, as is not 
unfrequently the case in summer and autumn, it must 
be considered that there is a further increase of inten- 
sity, the disease remaining the same excepting only 
in degree. 

Intermittent fever rarely comes on suddenly and 
without premonition ; or rather, to be more explicit, 
the disease is not suddenly and at once established, 
with its characteristics of cold, hot, and sweating 
stages distinctly developed. "When your patient in- 
forms you that he was attacked by the disease on a 
certain day, because on that day he had an ague, you 
cannot safely infer that this was the very beginning 
of the disease. On the contrary, you will find, upon 
proper inquiry, that he has had several obscure and 
ill-defined paroxysms previously, which have been 
marked by depression, headache, weariness, pain in 
the back and limbs, thirst, quickened pulse, and scan- 
ty and highly colored urine. Several such imperfect 
or indistinct paroxysms at regular periods, followed 
by perfect and distinct intermissions, precede most if 
not all the attacks of this disease, and the patient is 
often at a loss to know what is the nature of his mal- 
ady, and whether he is sick enough to require medi- 
cal treatment. He is scarcely aware, indeed, of being 
indisposed at all, excepting while the paroxysm is 
upon him. In many cases the patient will have made 
an effort to obtain relief in active exercise or an excur- 



38 Lectures on Fever. 

sion of pleasure, with unusual exposure and fatigue, 
which only served to hasten on the climax, and, when 
he least expected it, he was prostrated by an ague. 

In any event, after several imperfect and obscure 
paroxysms, perceptibly increasing in violence at each 
recurrence, we find that all the symptoms which char- 
acterize the disease make their appearance, and we 
have before us unmistakable evidence that our patient 
is suffering an attack of intermittent fever. There is 
a sensation of coldness creeping along the spine, such 
as is never experienced from the mere influence of 
cold air. The features soon become pale and shrunk- 
en, the ends of the fingers and toes cold, the finger- 
nails turn blue, and the papillae of the skin stand out, 
forming what is called goose-skin. In the beginning 
of a chill, the pulse generally becomes smaller and 
more frequent than in health, and the patient is also 
thirsty. The sensation of coldness soon overspreads 
the whole body, attended by shivering and shaking, 
with chattering of the teeth. This sensation of cold- 
ness conveys to the patient an idea of a much greater 
degree of cold than is found actually to exist, as de- 
termined by the thermometer or by the application of 
the hand ; just as a greater degree of heat is felt by 
the patient in the hot stage than actually exists, show- 
ing how susceptible the nerves of sensation become in 
both the cold and hot stages of fever. Pain in the 
head, with a sensation of tightness or constriction, 



Lectures on Fever. 39 

oppression at the precordia, dyspnea, and cough fol- 
low, with pain in the back and limbs, restlessness, 
nansea and sometimes vomiting, and, not unfrequent- 
ly, small watery dejections from the bowels, similar in 
appearance to those which characterize Asiatic chol- 
era, and sometimes these are involuntary discharges, 
on account of the relaxation of the sphincter ani. 

The hot stage of fever follows the cold in one to 
three hours. It is usually characterized by great heat 
of skin, a considerable increase in the force, frequency, 
and hardness of the pulse ; by thirst, dryness of skin 
and tongue, pain and throbbing in the head ; by rest- 
lessness, anxiety, and partial suspension of the secre- 
tions. The duration of this stage is generally somewhat 
longer than the other, sometimes extending to a pe- 
riod of eight or nine hours, and gradually subsiding 
into the last or sweating stage. This can hardly be 
called a stage of fever at all, inasmuch as it appears 
to be only the natural result of the previous excite- 
ment. The capillary vessels being now relieved of 
the turgescence and excitement, which for a time has 
precluded a free exercise of the nutritive and secerning 
functions, evince certain signs of restoration to their 
normal condition, although still so far excited as to 
cause excessive action in the secretions which follow, 
including that of the skin. This affords the patient 
great relief from previous suffering, excepting only 
that which arises from a manifest loss of strength. 



±0 Lectures on Fever. 

The time consumed by the cold and hot stages of 
fever varies considerably in different cases, and affords 
indications of the violence of the disease, as does, also, 
the length of the intermission. The shorter the one 
and the longer the other, the milder is the disease, 
and the reverse. 

If not influenced favorably by curative measures, 
the common tendency of intermittents is to anticipate 
the time of the paroxysm, by changing from the long- 
er to the shorter periods, or, in case the type is quo- 
tidian, commencing earlier in the day, and even as- 
suming the remittent type. This is the usual course 
among us when the disease is not relieved by treat- 
ment, and especially in sickly seasons. Still, the dis- 
ease has been considered to be of a self-limiting char- 
acter, with a natural tendency toward recovery ; and, 
in some exceptional cases, it does run a certain course 
without remedies, and terminates favorably. Of 
course, we cannot expect to meet with many such, 
were it only from the fact, that nearly all who are 
attacked by this or any other disease, are certain to 
receive treatment of some kind. Physicians may not 
always be employed, but patients fall into the hands 
of persons unskilled in medicine, who prescribe reme- 
dies with greater confidence than those who are. In- 
deed, the plan of treatment in uncomplicated cases is 
now so simplified, that many non-professional per- 
sons, adhering to the practice pursued by physicians, 



Lectures on Fever. 41 

are quite successful in their treatment. It is only 
when the disease is of a grave and malignant charac- 
ter, or complicated with serious local lesions, or when 
practitioners prefer to follow the teachings of charla- 
tanry, that great evils arise from such practice. They 
who have the good sense to pursue the proper course 
on such occasions, in the way of treatment, may be 
supposed, in general, to possess the judgment and dis- 
cretion to call in the aid of a physician at the proper 
time. 

There may be truth in the opinion so generally 
concurred in by physicians, that quartan agues are 
more difficult of cure than those observing shorter 
periods ; but we have a type prevailing among us 
which is more common, and certainly not less obsti- 
nate. This observes septenary periods — that is, it 
recurs every seventh day, or at some longer period 
which is a multiple of seven, even to forty-two days, 
and perhaps in some cases even longer. It is not apt 
to prove fatal, but is difficult of cure almost in pro- 
portion to the length of the period of intermission. 
This may be owing to several circumstances connect- 
ed with it. Local lesions, in the form of congestion 
or diseased hypertrophy, may exist, particularly in 
the spleen and liver, and, by their irritative influence, 
tend to perpetuate the fever as a symptomatic affec- 
tion. But a greater obstacle is presented to a ready 
and radical cure, in the difficulty of anticipating the 



42 Lectures on Fever. 

recurrence of the disease by the use of the proper 
remedies. It is always uncertain whether the parox- 
ysm will return at the first or any more remote sep- 
tenary period, which may depend upon some acci- 
dental occurrence at or near each one of these periods, 
either favorable or unfavorable to its production. 

The intermission is sufficiently long in any case to 
lead the patient and even the physician astray, as to 
the recurrence of the paroxysm, and the proper degree 
of vigilance in preventing its return is often wanting. 
Frequent changes in the periods of intermission, also, 
render it difficult to keep the run of these cases, and 
we are often surprised by the recurrence of the parox- 
ysm at an earlier or later day than w T as expected. 
These cases are liable to great obscurity at certain 
periods, and they are, indeed, sometimes so masked, 
as to make them difficult of recognition, unless the 
physician have the patient under constant super- 
vision. 

Another peculiarity which I must not forget to 
mention is, that this septan type generally originates 
in the quotidian or tertian, and when the paroxysm 
returns at a septenary period, however remote, the 
disease generally resumes its original type, and so 
continues either quotidian or tertian until arrested by 
treatment, when it again becomes a septan ; and these 
changes may be many times repeated. I have known 
fevers of this kind to continue in this way for years, 



Lectures on Fever. 43 

and finally yield only to the influence of some sudden 
change of treatment, to change of climate and method 
of living, breaking up old habits and associations. 
In general, however, the disease may be overcome by 
the proper use of the anti-periodic treatment during 
all the period of intermission, with increased doses 
and other attentions, for a few days, in anticipation 
of the returning paroxysm. Many of the relapses of 
fever which are constantly occurring, and presenting 
so many difficulties, I have no doubt are of this char- 
acter, and require to be treated in the manner just in- 
dicated. For the want of proper remedial measures, 
this form of fever sometimes continues for several 
years, giving rise to chronic gastric, hepatic and 
uterine diseases, commonly found to be difficult of 
cure. The relief which we are able to afford such 
cases without anti-periodic treatment, is not perma- 
nent. The disease is ever recurring, and the patient 
is often driven from one physician to another, and to 
the use of a great variety of expedients and nostrums, 
until, from the effects of disease and quackery togeth- 
er, incurable derangements of certain organs super- 
vene, and a lingering and painful illness ends in death. 
This septan intermittent is often so obscure as to be 
difficult of detection until after several paroxysms 
have occurred. I have known cases in which nei- 
ther the patient nor physician could be quite cer- 
tain of the true character of the disease, until after 



44 Lectures on Fever. 

several returns of it. In one instance of several 
years' duration, the paroxysms recurred generally at 
intervals of twenty-one or twenty-eight days, and 
then the disease always assumed the tertian type, un- 
til relieved by treatment. The first paroxysm was 
marked by no other noticeable symptom than a pecu- 
liar weakness in the knees. The second exhibited, in 
addition, a little headache, and pain in the back, 
with slight evidences of febrile excitement ; but with 
only such moderate development of the disease as not 
to interfere with the usual occupation of the patient. 
But the third tertian paroxysm was distinctly marked 
in all its stages, although the chill was still slight, and 
brought the patient — a feeble woman — to her bed. 
Efficient treatment being then resorted to, the fever 
was arrested, and she enjoyed an intermission of twen- 
ty-one or twenty-eight days from the last tertian par- 
oxysm, when the disease returned as before. Fe- 
males, I suspect, are more liable to these attacks than 
males, and sometimes the recurrence of the fever cor- 
responds with the menstrual period ; or, rather, there 
is a concurrence of the two affections whether the in- 
termission be longer or shorter. And it is remarka- 
ble that this correspondence continues during the 
whole period of pregnancy, each return being at- 
tended by all the usual symptoms of menstruation, ex- 
cept the vaginal discharge, and sometimes even this 
is not wholly absent. I have observed, also, that dys- 



Lectures on Fever. i5 

menorrliea is sometimes complicated with these sep- 
tenary agues, and that it is not to be cured without 
overcoming the febrile concomitant. 

Many curious anomalies occur in connection with 
intermittent fever, with which it is important for the 
student to become acquainted, that he may not be 
compelled to learn them from experience alone. From 
apparently trivial causes, it sometimes recurs at irre- 
gular periods, and when least expected, even after 
the patient thinks himself thoroughly cured. Expo- 
sure to cold, a wetting in a shower of rain, sudden 
chauges of temperature, wet feet, imprudence in diet, 
mental emotion, drinking iced water or cold milk, and 
many other things which shock or disturb the sys- 
tem, and especially the stomach, not only bring on 
the chill, but change the type and the time of the 
paroxysm. Dr. Gregory relates the case of a student 
of medicine, who brought on a paroxysm after a long 
exemption, by striking his shin against the scraper of 
the class-room. Dr. Brown, the author of the article 
on this disease in the Cyclopedia of Practical Jledi- 
eine, says, he was stationed at Canterbury, in August, 
1814, with a corps of cavalry, of which he had medi- 
cal charge, and which had recently returned from the 
Peninsula, where many of the officers and soldiers, 
perhaps the majority, had labored under agues. The 
wind set in suddenly and coldly from the east, and 
immediately his hospital was filled with intermittents. 



46 Lectures on Fever. 

An occurrence similar to this took place under my 
own observation. In the autumn of 1848, a large 
number of negroes upon a cotton plantation, which 
had a working force exceeding one hundred, had in- 
termittent fever, and many of them had suffered one 
or more returns of the disease, or relapses. By the 
time cold weather set in, however, they had all recov- 
ered, and several weeks elapsed without the recur- 
rence of a single case. Upon a certain day, the wea- 
ther being warm, sultry, and rainy, these negroes 
were employed in a field very elevated, and exposed 
to strong currents of air. Toward evening, a brisk 
breeze struck up suddenly from the north, and the 
slaves with their thin and wet clothing were exposed 
to its influence. They returned home much chilled, 
and the succeeding day every one who had suffered 
with fever during the autumn had a return of it ; and 
all had symptoms of pulmonary congestion and in- 
flammation. In their previous attacks, earlier in the 
season, the local lesions were in the viscera of the ab- 
domen, but now, under the influence of this exposure 
to sudden cold, they were all, principally, thoracic. 

There are cases of this kind to be met with every 
year, throughout the Southern States ; but attacks of 
intermittents complicated with thoracic lesions in 
cold weather, are not confined to those persons who 
have had intermittents previously, although in gene- 
ral such persons are more liable to them than others. 






Lectures on Fever. 47 

Individuals who have enjoyed perfect health, during 
all the previous summer, and even immigrants into 
malarious regions, and those who have never had in- 
termittent fever in their lives, are liable to be thus 
attacked ; showing that the cause of periodic fever is 
not wholly destroyed by cold weather, but continues 
to act in certain localities all the winter, with only an 
abatement, perhaps, in its intensity. 

Some authors speak of masked intermittents, which 
never come to the full development of the character- 
istics of the disease, so as to exhibit the usual cold, 
hot, and sweating stages ; and there can be no doubt, 
as I have before remarked, that in the forming stage 
there is often great obscurity in the symptoms ; but 
in general, I suspect, if there be a febrile movement 
at all, it will, unless arrested by antiperiodic treat- 
ment, show unmistakable signs of its existence. Cases 
not thus developed may more properly be considered 
diseases of periodicity without fever. Many diseases 
purely nervous take this form, and sometimes they 
are attended by distinct rigors, but these do not ob- 
serve regular periods, and are not followed by febrile 
excitement, or the sweating stage. In situations 
where the cause of periodicity is rife, nearly all pre- 
vailing diseases assume the periodic character, and it 
is because this feature passes unobserved that such 
diseases are sometimes of such long continuance, and 
so difficult to cure. Besides neuralgia and rheuma- 



48 Lectures on Fever. 

tism, erysipelas, and catarrh, we meet with dysentery, 
diarrhea, and dyspeptic affections, which are of this 
periodic character, and without febrile excitement. 
Certain uterine affections come also within this de- 
scription of disease ; and infantile diarrhea and cho- 
lera infantum are particularly liable to such compli- 
cation ; and in the case of children, it is apt to be in- 
volved in greater obscurity than in adult persons. 
Escaping the notice of the physician, all the plans of 
treatment ordinarily resorted to in these infantile dis- 
eases fail of permanent success ; and this is, in my 
opinion the true explanation of the frightful mortal- 
ity occurring among children in certain places and 
seasons, from a class of diseases ordinary curable. 

Intermittent fever is sometimes termed malignant, 
from the great severity of some of its symptoms, and 
the consequent fatality of the disease. Most of the 
deaths reported as caused by congestive chill, may be 
regarded as of this class. But all chills may with 
propriety be called congestive, inasmuch as conges- 
tion is one of the gravest of the pathological pheno- 
mena connected with, or caused by, the cold stage 
of fever. Most of these congestions are supposed to 
exist in the large venous trunks of the thoracic and 
abdominal viscera, including the portal veins; and 
sometimes also in the cerebral circulation. The symp- 
toms attending chill sometimes indicate the existence 
of excessive, and even long-continued venous en- 



Lectures on Fever. 49 

gorgements, the concomitants of which are, the im- 
pairment of nervous power, the suspension of nutri- 
tion and secretion, and the derangement of the arte- 
rializing process going on in the lungs. Unless speed- 
ily relieved of these evils, we must expect that the 
patient will die without reaction, or that the founda- 
tion will be laid for such serious local lesions as will 
very materially interfere with all successful treatment, 
and perhaps become troublesome sequelce after the 
fever has been subdued. It is some evidence, per- 
haps, of the close connection existing between the 
chill and congestion, that patients who suffer most 
severely from the latter are scarcely relieved from the 
former during all the hot stage which follows. Chills 
still continue to annoy them, and to haunt their ima- 
ginations with constant fear of returning ague, even 
until the reactive process, which in these cases is irre- 
gular and imperfect, has subsided, and free perspira- 
tion becomes fully established. 

In such cases as these, however, if the patient sur- 
vive the cold stage, and reaction becomes established, 
the paroxysm is very likely to be prolonged, so as to 
preclude the occurrence of a distinct intermission, 
and the fever consequently assumes the remittent 
type, and in this way confirming our views as to the 
grave character of the disease. Such is indeed the 
true history of many of the cases of remittent fever 

which occur among us. They are at first intermit- 
3 



50 i Lectures on Fever. 

tent, or promise to be so, and generally of the quoti- 
dian type, the early paroxysms being indistinct and of 
trivial intensity ; but not being relieved by treatment, 
and frequently suffering injury by injudicious expo- 
sure, the disease rapidly gathers force and severity, 
and results in the form of attack, course, and termi- 
nation, such as I have now described. It is but a 
simple «and easy transition from one type to the other, 
in such a case, merely from an increasing intensity of 
the morbid action, and not from any change whatever 
in the character of the disease, or from any mingling 
of types under the operation of distinct causes. This 
transition from the intermittent to the remittent type 
can only be prevented by such remedial measures as 
will abate the violence of diseased action in the early 
stage. Any such abatement must create a tendency 
toward longer and more distinct intermissions, and 
toward shorter and less violent paroxysms ; and this 
shows the importance of early treatment, especially 
during the prevalence of the graver forms of fever. 
But I shall take occasion to urge this matter in a 
future lecture. 



LECTUEE IV. 

ESTERMITTEXT FETEE. 

It is when we come to consider the treatment of a 
disease that we find it necessary to study its patholo- 
gy, without a knowledge of which we are groping 
pretty much in the dark. Although the pathology 
of fever in many of its parts is so imperfectly under- 
stood, yet it appears to be established by pathologists 
that in the cold stage the large bloodvessels, and par- 
ticularly the veins of the abdominal and thoracic vis- 
cera, including the portal system, become greatly en- 
gorged with blood in all cases of severity. These 
engorgements, accompanied by a circulation propor- 
tionally sluggish, are supposed to be increased in the 
ratio of the violence and duration of the cold stage, 
but whether as cause or effect cannot now be deter- 
mined. The necessary effect of this disordered con- 
dition is, to engender certain visceral obstructions, 
which finally result in hypertrophy, or in chronic in- 
flammation ; and thus constitute those troublesome 
local lesions, which always embarrass the physician 



52 Lectures on Fever. 

in his treatment, and, indeed, often present the most 
serious obstacles to success. 

These congestions, always the condition to a great- 
er or less extent of the cold stage, may by persistence 
become the cause of its protracted continuance. In 
this case, the coldness and shivering continue to be 
felt, notwithstanding the partial or ataxic reaction. 
The lungs, liver, and spleen feel the influence of this 
remora of the venous trunks more than other organs; 
and hence the liability of these viscera to become the 
seats of the more permanent forms of congestion, and 
of the chronic inflammations which follow protracted 
cases of intermittent fever, and which we often find 
more difficult of cure than the original disease. 

Stasis of the blood in certain parts of the venous, 
and perhaps also, in some degree, in the arterial 
system, is a pathological condition common to all the 
forms of febrile disease in their cold stage, to Asiatic 
cholera, sunstroke, etc. And it is remarkable, that 
this state of disordered circulation, proceeding prob- 
ably from nervous irritation, should, however severe, 
leave the mind of the patient almost wholly undis- 
turbed. It is only in the hot stage, when reaction 
becomes violent, attended by great cerebral excite- 
ment ; or in the declining period, when the nervous 
energy has been prostrated by disease, and a fatal ter- 
mination has become imminent, with signs of asthenic 
congestion in the brain, that the mental faculties be- 



Lectures on Fever. 53 

come seriously impaired. In the cold stage of fever 
there is always congestion in the lungs, as is evidenced 
by oppression, pain, and constriction in the chest, at- 
tended by difficult or labored respiration, and a want 
of due arterialization of the blood. The voice be- 
comes husky also, from this cause, and sometimes 
loses its proper resonance. In cold weather this 
congestion is prone to run into inflammation, consti- 
tuting the disease commonly called intermittent 
pneumonia, the lesions of which are sometimes of a 
serious and permanent character. 

It is not unfrequently the case, as I have already 
intimated, and particularly in persons of robust hab- 
its, that the sensation of chilliness continues, alternat- 
ing with flushes of heat, during all the hot stage, and 
sometimes after pretty free perspiration is established. 
The patient, under such circumstances, becomes ex- 
ceedingly restless. He covers himself up and throws 
off the covering in rapid succession ; tosses about in 
his bed, rolling from side to side ; complains of ex- 
cessive thirst, and of feeling hot and cold at the same 
time, or in quick succession ; says the chilly sensa- 
tions are those caused by a stream of cold water run- 
ning down the spine ; and he expresses by fits and 
starts strong apprehensions of a return of the ague. 
These are symptoms of serious and persistent conges- 
tions, and, if not soon relieved by treatment, the pa- 
thological condition which they indicate will be likely 



54 Lectures on Fever. 

to result in active inflammation, and thus lay the 
foundation of sucli local lesions as are difficult of 
cure. Many times, no doubt, they result in speedy 
death, and then the patient is apt to be reported in 
the bills of mortality as having died of congestive 
chill. 

These being some of the more prominent manifest- 
ations of the cold stage of intermittent fever, it is very 
desirable that we should be able to ascertain, if possi- 
ble, what is the immediate cause of them, that means 
may be adopted to relieve the patient from its mor- 
bid effects. Of this cause, however, little or nothing 
is yet known, except what may be deduced from the 
pathological conditions before referred to, and whether 
these are produced by the influence of the fever poi- 
son on the solids or the fluids of the body, upon the 
nervous or the vascular system, has long been, as I 
have before remarked, a subject of doubt and dispute. 
But it cannot be denied that one of the earliest man- 
ifestations of disease is a stasis of the blood ; and it 
is equally certain that this condition may be relieved 
by the use of those remedies, the action of which is 
supposed to be particularly directed to the functions 
of the nervous system. This stasis of blood does not 
necessarily imply the existence of any morbid changes 
going on in that fluid, and probably in the inception 
of the disease there are none ; but we have reason to 
believe that the blood becomes diseased in a very short 



Lectures on Fever. 55 

space of time, by any interference with its healthful 
circulation, whether impeded or accelerated in its 
movements. In this case we have the evidence of our 
sense of sight to determine that the blood becomes 
thicker and of a darker color, almost in proportion to 
the time of the continuance of the congestion. 

According to these views on the pathology of the 
cold stage, it is legitimate to infer, contrary to the 
common practice, that it is the proper time for the 
application of active remedial measures. The con- 
gestions constituting mainly the disease have only to 
be removed to obtain relief of present symptoms, and 
to guard the system against subsequent diseased ac- 
tion dependent upon this condition. And here the 
question arises— more important than any, having ref- 
erence merely to the theory of the disease — what is 
the treatment to be adopted ? Our patient is shiver- 
ing with cold, and must be warmed. His circulation 
is languid, and requires excitation. He is suffering 
from debility, and demands support. Does it not 
readily occur to every one present in the sick-room 
that the indications are for the heating, excitant, in- 
vigorating treatment ? Nothing appears more rea- 
sonable ; nothing is more common ; but nothing is 
more inappropriate. Sthenic congestion, like this, is 
not to be relieved by excitants and tonics. Sedatives 
and narcotics are the remedies indicated. Millions of 
lives have been sacrificed to sthenic congestion, for 



5G Lectures on Fever. 

the want of a proper understanding of this subject, and 
therefore it is a question of great interest to the stu- 
dent of medicine. 

Not to go farther back than the time of Cullen, we 
find that he promulgated a system which had for its 
basis the assumed existence of debility in such cases ; 
and that while he was denouncing the practice of 
founding new medical theories upon false facts, he 
was himself enabled to establish a system, which was 
for a time almost universally received as true, and 
which has influenced other theorists even to the pres- 
ent day, having no better support than the assump- 
tions so loudly condemned in others. From his au- 
thoritative teachings, the bugbear debility found its 
way into every theory of fever, and gave tone and 
direction to every system of therapeutics. It over- 
spread the world as with a pall of fatal error, the 
gloom of which has not yet been wholly dispersed by 
the rays of modern science, and by the illuminations 
of the Baconian philosophy. It is important that you 
should be enabled to resist these potent influences, 
and to learn, that it is not debility with which you 
have to contend in ague, but the very reverse, plethora 
and sthenic congestion. Of the truth of this, you 
have sufficient evidence in the vigorous reaction 
which follows. 

Opium, in view of the nervous character of the 
chill, may be successfully used to overcome the irrita- 



Lectures on Fever. 57 

tion which lies at the foundation of the congestions in 
certain of the viscera. When given in full doses, and 
in the very inception of the disease, the relief afford- 
ed is positive and striking. The venous engorge- 
ments gradually subside under its influence, the blood 
flows on more freely in its natural course, tending to 
equalize the circulation in all parts of the body, and 
also the animal heat, checking at the same time the 
chill and shivering which attend upon, and which are 
perhaps caused by, the temporary and partial suspen- 
sion of power in that portion of the nervous system 
which presides over the circulation of the blood. 
When relief is thus afforded, the pulse, from being 
small and rapid, becomes in a short time full and reg- 
ular, the febrile reaction is facilitated and at the same 
time moderated, and the patient passes through the 
hot stage with comparative ease and rapidity. All 
this seems to be sufficiently favorable, and in many 
cases these results may be readily secured by the 
judicious use of opium ; but there are objections to 
the practice which are worthy of careful attention. 
The secondary effects of opium are, to impair the tone 
of the digestive organs, cause more or less of cere- 
bral torpor, suspend to a considerable degree the se- 
cretions, and produce constipation of the bowels. 
Unless measures be taken to obviate these difficulties, 
more or less of discomfort, and not unfrequently seri- 
ous hindrances to a final cure of the disease, follow. 



58 Leehtres on Fever. 

Just in proportion to the severity and continuance of 
the disease, and the consequent suspension of glandu- 
lar action, does the use of opium appear to become 
objectionable. You will find, that in the several 
stages of all forms of febrile disease, when nervous 
derangement is partially relieved, the secretions, ex- 
cepting in some cases those of the skin and bronchial 
tubes, are impaired or suppressed by the use of opium ; 
and in those forms commonly denominated malignant, 
it is liable to produce even fatal effects. 

Chloroform in doses of a fluidrachm, more or less, 
and repeated as its effects subside, will accomplish in 
most cases all that can be expected of opium in re- 
gard to the nervous system, and without the objec- 
tionable features of the opium practice. I have had 
less experience with this remedy than with the other, 
but it appears to possess all the power of opium over 
the irritative stage of fever, and it may be given 
without those risks of injury to the digestive, cere- 
bral, and glandular functions to which I have al- 
luded. I have known the chill of an intermittent to 
be relieved by it more promptly and effectually than 
by any other remedy, moderating also the stage of re- 
action to an extent which rendered it almost imper- 
ceptible ; thus placing the patient, with little loss of 
time, in a condition to receive the proper treatment 
for the period of intermission. This remedy is said 
to have been administered with similar effects by in- 



Lecture* on Fever. 59 

halation, but I have not used it in this way for such 
purpose, and should deem the exhibition by the sto- 
mach preferable on the score of safety. No risk of 
fatal or injurious effects is incurred by the use of chlo- 
roform in drachm doses, but it must be borne in mind 
that its effects are much less permanent and lasting 
than those of opium, a frequent repetition of the dose 
being necessary to a prolonged influence of the rem- 
edy.* 

Narcotism, from an early period in medical prac- 
tice, in whatever way produced, has been considered 
remedial in intermittent fever, and doubtless it is so 
in the cold or irritative stage. The use of narcotics, 
in some form, has been common, also, in all the varie- 
ties of charlatanry. Opium, aconite, cannabis, coni- 
um, stramonium, arnica, hyoscyamus, hamulus, lactu- 
carium, hellebore, nicotianum, gelseminum, etc., have 
all been used with varying success ; to which may be 
added alcohol, ether, camphor, and chloroform ; not 
forgetting the soothing influences of music, and of 
monotonous sounds. Narcotina, it is said, may be 
successfully substituted for any and all other narco- 
tics, as quinia is for cinchona. The widespread and 
long-continued use of such means would seem to favor 
the opinion, that fever in its early stage is essentially 
a nervous disease. 

* These views, put forth in 1852, have been fully confirmed by sub- 
sequent observation, 



60 Leotwes on Fever. 

Bloodletting has been found to operate not less 
promptly and favorably than narcotic remedies, in af- 
fording relief to sthenic congestion connected with 
the chill of intermittent^. It is supposed to operate 
by unloading the engorged bloodvessels, and thus 
facilitating the movement of the blood. Perhaps it 
acts by restoring cerebral and nervous energy. Par- 
ticular organs are relieved of congestion by topical 
bleeding in their vicinity ; and a similar effect is said 
to be produced, but somewhat less promptly, by re- 
taining a considerable portion of venous blood in the 
limbs by means of tourniquets and ligatures ; thus af- 
fording partial relief to internal organs of the remora 
by which they are oppressed. But whatever may be 
the nature of its action, there can be no doubt of the 
efficacy of bloodletting in the relief of congestion in 
chill and kindred affections. Before the introduction 
of chloroform, I gave it a preference in general over 
opium, because not only of the prompt relief afforded 
by it, but also of its better influence over the subse- 
quent stages of the disease. Even now, when it so 
happens that decided relief has not been obtained by 
other means, and particularly when there is evidence 
of partial reaction, attended by hard pulse and febrile 
heat, accompanied by chilly sensations, bloodletting 
is to be preferred over all other remedies. 

In this connection it must be particularly observed, 
however, that in the use of bloodletting for the relief of 



Lectures on Fever. 61 

sthenic congestion, great caution mnst be exercised on 
account of the temporary depression of vital or nervous 
power in such cases, and the liability, by consequence, of 
collapse from sudden depletion. Reaction is to be in- 
duced, in cases of severity, by the abstraction of blood 
slowly, or by bleedings several times repeated. It 
sometimes happens, that faintness is produced with the 
patient in a sitting posture, by the sudden loss of only 
a few ounces of blood. But after several small bleed- 
ings, with proper intervals of rest, some degree of 
general reaction will have been induced, and then a 
freer loss of blood can be borne without inconveni- 
ence. A large and sudden abstraction of blood in 
such case would be likely to prove fatal ; but the dan- 
ger of this is very much lessened by the fact, that in 
general it is impossible to draw from a vein, in the 
outset, any such quantity of blood. The veins may 
be full and large, and one being freely opened with 
the lancet, the blood will flow in full stream for a mo- 
ment, and then cease almost entirely ; it will come 
trickling down the arm, and fall into the vessel, thick 
and dark, drop by drop. The venous circulation is 
too sluggish for the blood to run freely ; perhaps its 
passage from the arteries to the veins, through the 
capillaries, is retarded for want of nervous energy ; but 
when a partial relief of the remora is obtained, then 
the required quantity may safely be taken in a full 
stream, and with great relief to the patient. 



62 Lectures on Fever. 

Care must be taken also not to confound the sthenic 
congestion of chill, with that which attends upon an 
asthenic condition of the system, arising from hemor- 
rhage, or other cause of prostration, and which in its 
external manifestations is very similar. Bleeding af- 
fords relief in both cases much alike ; but while in the 
former the strength of the patient improves from the 
loss of blood, and the relief thus afforded is durable, 
in the latter the strength is impaired, and the symp- 
toms of congestion return with increased force. It is 
just in this way that superficial observers are some- 
times led into fatal error by anemic congestion. Each 
bleeding enhances the evil sought to be remedied by 
it, although decided relief may be temporarily afford- 
ed every time venesection is repeated. I have known 
a feeble woman to be bled in this way until she be- 
came exsanguious, and died of exhaustion. Opium 
and chloroform, and even alcoholic stimulants, and 
the preparations of iron, are more suitable remedies 
for anemic congestion, together with nutritious food. 
The sudden prostration of the system in sunstroke, 
and from taking large draughts of cold water while 
the system is heated by exhausting exercise, proceeds, 
I apprehend, from asthenic congestion, and these af- 
fections are to be relieved by opium, chloroform, and 
tonic remedies, and especially by full doses of chloro- 
form.* 

* Since this was written, I have had some experience with chloro- 



Lectures on Fever. 63 

Excitant remedies are generally recommended dur- 
ing the chill, and under certain restrictions they are 
■useful. As there is no permanent debility to be over- 
come, but only temporary prostration from a sluggish 
circulation of the blood, no other than the most evan- 
escent stimulants should be given, such as ether and 
carbonate of ammonia. Externally, the most effectual 
is mustard. So powerful indeed are sinapisms in 
these cases of temporary vital depression, that I have 
often felt inclined to attribute to them other virtues 
than those of a mere rubefacient. Certain it is, they 
are more effectual than other remedies of this class. 
Even in cases where bloodletting is indicated and es- 
sential to relief, vitality often requires to be sustained 
by stimulation, at the same time that the lancet is 
used. Without this in violent cases of sthenic con- 
gestion, sudden and dangerous prostration might fol- 
low the loss of even a small quantity of blood. We 
meet with few diseased conditions in practice which 
require more care and skill in the treatment than 
these -of great prostration of vital power from conges- 
tion, arising from whatever cause it may. The most 
common causes are chill, hemorrhage, and concussion ; 
but sometimes formidable cases arise from some ner- 

form in sunstroke, fully confirming this view. It may be given with 
prospect of relief, even after the sufferer is unable to swallow other 
remedies. Pure chloroform poured into the mouth will be swallowed 
after the patient is insensible, and unable to swallow water. 



64 Lectures on Fever. 

vous derangement in pregnancy, and in dysmenor- 
rhea, requiring skill and judgment in their treatment ; 
for it is not always an easy matter to determine, on 
the instant, whether the disease be of a sthenic or an 
asthenic character. 

Emetics are often useful in relieving patients of 
chill, and their application seems to be indicated by 
the operations of nature ; for we find it very common 
for vomiting to occur during a chill, and in cases of 
congestion from other causes, and some degree of re- 
lief is obtained from it, together with a tendency to 
reaction, with returning warmth, and an equalization 
in the circulation of the blood. Tartar emetic is our 
best remedy for this purpose, because of its prompt 
action and contrastimulant effect ; but for children the 
ipecacuanha is a safer remedy, and for them, it is 
scarcely less efficient. 

The hot stage, which usually follows the chill in 
from one to three hours, requires the application of 
those remedies w T hich have the effect to mitigate and 
subdue excitement. Bloodletting, when it has not 
been previously and sufficiently used in the chill, be- 
comes necessary in the stage of reaction, whenever 
the febrile excitement is so violent as to endanger the 
integrity of vital organs. Its curative power is prob- 
ably less in the hot than in the cold stage, but it may 
be used with less danger of any immediate prostration 
of strength. For internal use, I have found nothing 



Lectures on Fever. C5 

so valuable as the tartar emetic, in small and fre- 
quently repeated doses ; and generally its efficacy is 
increased by the simultaneous use of the nitrate of 
potassa. This may be given in ten to twenty-grain 
doses, and even in larger quantity, conditioned upon 
the ability of the patient to swallow and retain a 
large quantity of diluent drink, which seems to be 
necessary to prevent the irritative effect of the nitrate 
of potassa upon the coats of the stomach. The uncer- 
tainty about this makes it better not to combine the 
two remedies, but to administer them separately. 

To obtain the best effects of tartar emetic as a fe- 
brifuge, it must be given in such doses as to cause and 
sustain a slight degree of nausea, without vomiting. 
You may begin with doses of one sixteenth of a grain, 
and repeat it every hour, or half-hour, increasing the 
quantity very gradually, until the patient complains 
of slight nausea, and then the object will be to sus- 
tain this nausea ; to do which it will sometimes be 
necessary to increase the close to one eighth of a grain. 
Indeed, some will require this from the beginning. 
Should the nausea become distressing, and vomiting 
occur, the medicine may be suspended for two or 
three hours, and then upon resuming it the patient 
will bear larger doses than before. But it is import- 
ant to know, that whenever there is a strong tendency 
to gastric disorder, and especially in yellow fever, the 
prominent local lesion in which is gastritis, tartar 



Q6 Lectures on Fever. 

emetic is always injurious, and cannot be used. This 
is one of the great difficulties in treating this formi- 
dable disease. We have to forego the use of our best 
febrifuge remedy. This medicine unfortunately is 
frequently adulterated. It should always be pur- 
chased in the crystals. 

Cold water is a most valuable refrigerant remedy in 
the hot stage of intermittents, and, besides forming 
the principal drink, it should be freely applied ex- 
ternally, and particularly about the head and shoul- 
ders, the extremities being kept warm. But the most 
powerful refrigeration is produced by using cold wa- 
ter in the form of enemata ; while by this means also 
the lower bowels are relieved from the irritating 
influences of accumulations of fecal matter. Local 
bloodletting must sometimes be resorted to, to relieve 
certain organs of tendencies to serious local lesion. 
The brain and the viscera of the thorax and abdomen 
are all liable to become implicated in the morbid ex- 
citement of fever, to an extent which seems to be be- 
yond the power of general remedies to cure. I have 
often known headache, dyspnea, vomiting, and pain 
in the viscera, to resist every means of general treat- 
ment, until cups or leeches w r ere freely applied in 
close proximity to the suffering organ. Blisters and 
sinapisms, as well as various rubefacient lotions, are 
used for the same purpose as local bleeding ; but they 
are, in general, less efficient ; and sometimes it is im- 
proper to use them to much extent, while a high state 



Lectures on Fever. GT 

of febrile excitement exists, lest they may increase 
the local inflammation by sympathy ; and this is the 
very time when relief is most needed. 

The supposed signs of inflammation which seem to 
call for these measures of relief, are sometimes reme- 
died by the pretty free exhibition of opium ; hence 
the credit which this remedy obtains with many in 
the treatment of inflammation. But, I think, if you 
observe its effects carefully, in all the different stages 
of fever, you will agree with me, that our principal 
chance of benefit in the use of opium is in the form- 
ing or irritative stage. When inflammatory action is 
established, and the functions of nutrition and secre- 
tion suspended, opium is always injurious. And this 
is not only the case while undue arterial action contin- 
ues, but upon its subsidence, and until the functions 
of nutrition and secretion are well established. As 
opiates are in such general use in the treatment of 
disease, you will do well to remember the caution 
conveyed by these remarks. The physician meets 
with no greater temptation in practice than that of 
affording present and temporary relief to painful 
symptoms by the use of opium. Many times he gains 
credit to himself by such exercise of skill, when the 
ultimate suffering and danger are greatly increased, 
and even such mischief done as proves irremediable. 
It is always bad practice to secure present comfort 
and approbation at the risk of subsequent evil ; and 
when human life is endangered by it, it is criminal. 



LECTUKE Y. 

INTERMITTENT FEVER. 

The sweating, which follows the hot stage, is a 
period of comparative rest and relaxation, and an 
effort of nature to return to the healthful performance 
of the functions. These healthy movements, having 
been for a time partially suspended, are resumed with 
increased vigor. This appears to be the natural con- 
sequence of the sudden restoration of nervous energy ; 
and the patient is, to all appearance, once more free 
from disease. He passes through the intermission, 
whether longer or shorter, with little other signs of 
deviation from health than a partial loss of muscular 
strength. It is one of the unexplained phenomena of 
intermittents, that the patient should, during all the 
period of intermission, seem to be free from disease ; 
and yet be liable to a return of the febrile paroxysm 
after a stated interval, with evidence of increased vio- 
lence at every such recurrence. To prevent such re- 
turn is now the object of treatment, and we are 
fortunately in possession of means of cure, which, if 
judiciously applied, are so certain in their effects, that 



Lectures on Fever. 69 

it is a reproach to a physician not to be able to ac- 
complish such object. The process is, indeed, so 
simple, that even unprofessional persons soon learn 
the necessary routine of treatment, which enables 
them, in uncomplicated cases, without the least know- 
ledge of pathology and therapeutics, to conduct such 
cases to a favorable issue. 

Quinia, in some of its combinations, is the remedy 
most relied upon in the treatment of intermittents, 
the bisulphate being most commonly used ; and it is 
an object of the first importance to learn how to em- 
ploy this remedy, so as to secure the most prompt 
relief, with an expenditure of the least possible quan- 
tity. Many different plans of exhibition have been 
proposed, and such is the remedial power of quinia, 
that cures are effected by all of them. Each has, ac- 
cordingly, its advocates ; but I suppose there can be 
little doubt that the best effects of quinia are to be 
secured under precisely the same conditions which 
appertain to the most successful operation of diuretics, 
tonics, astringents, etc., namely, those w T hich favor 
secretion, nutrition, and absorption. These condi- 
tions exist, in their fullest extent, only in the inter- 
mission. Quinia I consider to be properly a contra- 
stimulant remedy, its efficacy as an anti-periodic de- 
pending, in some measure, upon the degree of seda- 
tion it produces. Nevertheless, it is undoubtedly 
true, that in the exacerbation of fever it acts, unless 



70 Lectures on Fever. 

given in very large doses, as an excitant, enhancing 
nervous and arterial energy, and, of course, increasing 
the intensity of the febrile action. To guard against 
this evil, if quinia be given in the exacerbation at 
all, which is quite unnecessary in intermittents, it 
must be used in such large quantity as will certainly 
produce sedative effects, subjecting the patient to 
those characteristic and sometimes painful effects of 
the remedy, which may be considered toxical. The 
fever may be subdued, and periodicity may be over- 
come by this method, but the nervous system is liable 
to receive a shock which may result in lasting injury. 
ISTervous sensibility and the vigor of all the senses are 
more or less impaired by it ; those of hearing and 
sight are sometimes nearly destroyed, and partial par- 
alysis and mental imbecility are entailed upon the 
patient for life. These are the mischievous effects 
which bring this valuable remedy into disrepute, and 
which deter some persons from using it at all. 

My advice to you, therefore, is, to give quinia in 
the intermission exclusively ; not because it will not 
effect a cure if given in the exacerbation also, but be- 
cause it is safer and more efficient given in the apy- 
rexia. Yarious plans in regard to the dose, and its 
repetition, have been recommended, no one of which 
deserves to be regularly followed, because different 
constitutions are differently affected by it, some per- 
sons being more readily impressed than others ; and 



Lectures on Fever. Tl 

allowances are often required to be made for the con- 
dition of the digestive organs. The plan which I 
have generally pursued is, to begin with the remedy 
in one or two pretty full-sized doses for the particular 
patient in hand — say five to ten grains — and then to 
repeat in doses reduced in quantity, according to the 
effects produced ; continuing it not only until the hour 
of the expected chill is passed, but until so much time 
has elapsed that there will be little danger of an at- 
tack ; and then it is suspended until the next period of 
intermission or expected return, when the same course 
is repeated with reduced quantities ; for the danger of 
a return of the paroxysm is very much lessened by 
every period passed under the influence of quinia, 
without its recurrence. 

It will readily occur to you, that the object of this 
plan of treatment is, to put the patient under the full 
influence of quinia some time before the hour of the 
expected paroxysm, and then to sustain this influence 
with smaller doses, as occasion may require, until all 
danger is passed. But a course of quininization quite 
the reverse of this is recommended by some ; that is, 
to begin with small doses and gradually increase 
them ; the objection to which is, that the anticipating 
chill sometimes comes on before the patient is brought 
under the influence of the remedy. There are cases, 
however, in which it is better to pursue a different 
plan from that just recommended. Sometimes the 



72 Lectures on Fever. 

patient labors under great distress from the sedative 
effects of qxiinia. In others there is an irregularity in 
the hour of the paroxysm ; the chill coming on either 
earlier or later in the day. In others, again, the type 
is complicated by becoming doubled, or is converted 
into one of longer or shorter intermission. In these, 
it is generally better to give the quinia in smaller 
doses — say two or three grains — and extend the treat- 
ment over a longer period of time. The patient may 
begin the course of quinia soon after the exacerba- 
tion has subsided, even in the sweating stage, and 
take from one to three grains every two or three 
hours, for several days and nights in succession, ex- 
cept while sleeping ; always taking care to reduce the 
dose or to prolong the intervals between them, when- 
ever decided quininism is produced ; but not on this 
account to suspend them entirely. This is, in fact, 
quite an efficient method of exhibition, and one which 
is successfully practised in the use of various nostrums 
for the cure of ague, and of which quinia forms the 
basis. 

The secret of success appears to be, in keeping up 
the action of the quinia without interruption. If 
the dose is small, it must be repeated the oftener. 
And it is important to observe, that when the effect 
is once fully established, as evidenced by roaring in 
the ears and partial deafness, much smaller doses are 
required to secure its continuance than it took to pro- 






Lectures on Fever. 73 

duce it. In many cases, even a single grain every 
two or three hours will prove sufficient to perpetuate 
this condition, and thus prevent a recurrence of the 
paroxysm. For the want of a knowledge of this fact, 
patients are sometimes served wdth much larger quan- 
tities of this remedy than are required to produce the 
desired result. No remedy in use, perhaps, is more 
decidedly cumulative in its effects than quinia. If, 
therefore, the large doses which are necessary to be 
given are often repeated, great discomfort and even 
injurious effects are likely to follow. 

There are adjuvant remedies also to be employed, the 
most important of which are diluent drinks. When- 
ever the system is in that condition which is favorable 
to absorption and secretion, their remedial effects are 
striking. Hence the credit which many vegetable 
substances, of little or no therapeutic power in them- 
selves, have obtained in the treatment of intermit- 
tents. It is the water of the tisane which is remedial, 
and not the ingredient which renders its exhibition 
agreeable to the patient. The effect is materially 
enhanced by inviting the action of the diluents to the 
skin by warm covering, without which their influence 
over the secretions is mainly directed to the kidneys 
In this way they are useful, too, no doubt, but accord 
ing to my experience, the maintenance of the secre 
tions of the skin is more important. While free per 
spiration exists, there is little danger of a chill. 



74 Lectures on Fever. 

But there is another feature in the disease which 
must receive attention, if you intend to render your 
patient secure, and that is, the danger of a recurrence 
of the paroxysm, or a relapse, on the seventh day, or 
on some other day, generally the multiple of seven, 
after the last appearance of fever. And this recur- 
rence of the disease may happen again and again, 
until, growing into a habit, it may become difficult of 
cure. In this way it is not very uncommon for inter- 
mittents to continue to harass the sufferer for several 
successive years. Quinia proves, in general, to be 
an effective remedy, if taken daily during all the inter- 
mission, or if its use is resumed a day or two before 
the expected paroxysm ; but in many such cases, and 
especially in such as have been much treated by 
quinia, arsenic proves a more certain remedy. 
The beneficial effects of quinia in the treatment of 
cases of this kind, is generally increased by the use of 
some of the preparations of iron. Bismuth, zinc, 
copper, and strychnia are all occasionally used, and 
not unfrequently the bark, in substance, answers a 
better purpose in this chronic form than the quinia. 
But it often happens that some alterative course is 
required, in addition to the antiperiodics. Mercury 
and iodine are the best remedies to answer this indi- 
cation, and it seldom happens that a patient suffers 
from a protracted intermittent without such local le- 
sions as require one or both these remedies for their 



Lectures on Fever. 75 

removal. It is not prudent, therefore, to neglect this 
matter, and confine our whole attention to the periodic 
movement. 

This extended course of medication may become 
necessary, from the fact that the patient is all the 
while exposed to the cause of the disease, and, not- 
withstanding its temporary suspension, a new period 
of incubation may be inaugurated, and develop its 
results in the usual time ; and this development may 
be hastened on by exposure, by errors in diet, me- 
chanical injuries, and any other occurrence which 
causes any considerable disturbance to the healthy 
action of the system. The chronic congestions and 
hypertrophies, which are apt to arise from intermit- 
tents of long continuance, may also act as exciting 
causes, and even produce symptomatic fever ; which 
will be dependent upon the proper cause of intermit- 
tents in their idiopathatic form, only so far as to give 
the disease the usual characteristic of periodicity. 

It is not always a matter of indifference as to the 
form of administering quinia. The most convenient 
is that of pills, and the sugar-coated pills now so ele- 
gantly prepared, have the advantage of saving the 
patient the annoyance of the bitter taste. But the 
absorption of the medicine is supposed to be some- 
what less rapid when given in this way, and should 
the patient be under the operation of a brisk cathartic, 
the pills will often pass entirely through the bowels 



76 Lecturer on Fever. 

without being dissolved. In such case, of course, no 
benefit can accrue from them. I have known patients 
to take many doses in this form, and with this result, 
before the cause of their non-action was discovered. 
Pills of the bisulphate of quinia, made up by an ad- 
mixture of elixir of vitriol, converting the quinia, in 
part at least, into a full sulphate, and rendering it 
proportionally soluble, answer a better purpose ; and 
whenever immediate action is required, the pills 
should always be made in this manner. But there 
are several other forms of exhibition, some one of 
which may sometimes be preferable to pills, in case 
of urgency. The quinia diffused in water, coffee, or 
tea, with the concomitant of some acid drink, is a 
good method. But if the bitter taste is not objected 
to, and for children, to which it is often difficult to 
administer the remedy in any other way, it may be 
given with still better effect in solution. Water, 
acidulated with tartaric acid or elixir of vitriol, or lem- 
on syrup, or glycerine, may be used as the solvent, 
and the bitter taste may be partially obviated by the 
addition of licorice. 

Opium is considered by many to be an important 
adjuvant to quinia. But you are all aware that 
quinia and opium are remedies of an entirely differ- 
ent character, and sometimes one may be indicated 
and not the other. It is mostly — perhaps exclusively — • 
in the irritative stage of fever, and in the very incep- 



Lectures on Fever. 77 

tion of the disease, that opium is useful. In the more 
advanced stages, when disordered functions have su- 
pervened, and it has become a prominent indication 
to restore secretion and nutrition, the use of opium 
and its salts is always objectionable, because the effect 
is, to increase the very evil that should be remedied. 
The objects sought to be obtained by opiates can, in 
general, be better secured by the use of some other 
narcotic, such as stramonium and hyoscyamus. 

A multitude of other remedies have, at various 
times, been urged upon the attention of the profes- 
sion as substitutes for cinchona and its salts ; but 
each and all of them have proved so far inferior to 
quinia in the estimation of medical men, as to fail 
of acceptance as such. Among these, arsenic deserv- 
edly holds the most prominent place, and is fully en- 
titled to be ranked next to quinia. w The common 
objection made to it is, that it cannot be relied upon 
to arrest a chill so promptly and certainly, and that 
its continued use for several days or weeks, subjects 
the patient to danger from its toxical effects. I have 
met with no confirmation of this apprehension in my 
practice, but have, on the contrary, observed less in- 
jurious effects from the use of arsenic than quinia ; 
and I am not by any means convinced that the for- 
mer is less prompt and efficient in its remedial influ- 
ence than the latter. Given in conjunction with 
quinia, arsenic produces the happiest effects, and 



78 Lectures on Fever. 

enables us to reduce the dose of quinia so as to 
avoid all unpleasant constitutional influences. In 
cases where the use of quinia is precluded by some 
idiosyncrasy of the patient, the arsenic is by far the 
best substitute I have ever prescribed. It is especial- 
ly useful, also, and superior to quinia in intermit- 
tent neuralgic affections, which rarely ever resist the 
curative power of this remedy, especially if aided by 
the use of stramonium, to moderate paroxysms of 
pain. In the intermission of fever, whatever may be 
the type, the patient may be brought under the ex- 
citant influence of arsenic almost as readily as under 
the sedative power of quinia, and there is scarcely 
less security against the recurrence of the paroxysm 
in the one case than in the other. But to obtain 
these favorable results, I have found it necessary to 
use the arsenic in substance, rather than the arsenite 
of potassa, or Fowler's solution. The latter formula, 
how convenient soever it may be, has proved much 
less efficacious in my hands, and also a less agreeable 
remedy. In full doses, it has the disadvantage of 
causing preternatural heat in the stomach, which 
alone is a very serious objection to its use, whenever 
there is gastric complication. None other than the 
pure crystallized arsenous acid should be used. It 
may be made into pills with gum and licorice, each 
containing one tenth or one twelfth of a grain, and, 
ordinarily, one such pill is sufficient for a dose, but in 






Lectures on Fever. 79 

urgent cases two may be given. Three tenths of a 
grain a day may be given to adult persons, and the 
duration of the course may be made to depend upon 
the production of constitutional influences, as evi- 
denced by the peculiar effects of the arsenic upon the 
eyes and eyelids. When these appear, it is prudent 
to suspend the remedy until they subside. Indeed, 
they are proofs that all has been accomplished by the 
remedy that can be at present, by establishing its 
constitutional action. 

Of the mineral remedies, zinc, iron, and copper are 
next to be preferred. The sulphate of zinc, in as 
large doses as can be borne without emesis, will often 
arrest the disease by itself ; and, w^hen united with 
quinia, it enables us to reduce the quantity of the 
latter materially. I have succeeded in curing septan 
agues of long standing by this combination, and have 
found the effect quickened and improved by the addi- 
tion of full doses of gelseminum. In anemic cases, 
the preparations of iron are more efficacious, but it is 
requisite that such doses be given as will produce 
fulness and pain in the head. I doubt whether there 
is much difference in the remedial efficacy of the va- 
rious preparations of iron ; and I have generally 
selected that most agreeable to the patient, or most 
easily exhibited. Sulphate of copper too has been 
highly recommended as an antiperiodic, but I have 
had little opportunity to judge of its powers from 



80 Lectures on Fever. 

personal observation. Sulphur, iodine, and the mine- 
ral acids have also been advised. The nitric acid is 
said to have very decided antiperiodic qualities ; but 
in my hands it has not proved very successful. To 
make it so, I apprehend, it must be used in doses in- 
conveniently large. 

Many and various are the vegetable remedies, other 
than those already mentioned, which are used in the 
treatment of intermittents. Some of them doubtless 
possess antiperiodic power, but in general they cannot 
be so concentrated as to become efficient on this ac- 
count, and in all probability they owe their good ef- 
fects mostly to the fluid used as a vehicle. As in- 
struments for the employment of diluent drinks, the 
numerous herbs in common use in the treatment of 
intermittents are to be regarded with favor, and to be 
ranked indeed among our most valuable adjuvant 
remedies. I know of several large plantations south 
of us, upon which the only remedy used for the cure 
of intermittents is a decoction of corn-shucks. This 
is pressed upon the patient with great assiduity, and 
in large quantities, while other measures are taken to 
secure full diaphoretic and diuretic effects. With 
such examples before us, we must acknowledge the 
propriety of encouraging the use of such means, at 
least as aids to other and more active remedies. 

As the spinal nerves have been supposed to have 
much to do with the phenomena of fever, various 



Lectures on Fever. 81 

applications to the spinal column have been recom- 
mended as remedies, or preventives of chill. Among 
the most prominent are, dry cupping, sinapisms, and 
other rubefacients, and long-continued clapping with 
the hand, or a strap. Each of these has its merits, 
and I have witnessed good effects from them, and es- 
pecially the last. The effect is to equalize, in a meas- 
ure, the circulation of the blood, relieve nervous tor- 
por, divert the attention of the patient, and produce a 
comforting glow of warmth over the whole body. If 
it be true, as I have supposed, that intermittent fever 
in its early stages is a nervous disease, there are good 
reasons for attention to all those agencies in its treat- 
ment, which promise wholesome influences over ner- 
vous power. And it is upon this principle, I sup- 
pose, that we are advised to resort to the use of nar- 
cotic remedies, which were more relied on in ancient 
times than they are now. This practice, like many 
others formerly in high repute, has been too much 
neglected, since the profession have come to look upon 
quinia as possessing almost specific power over peri- 
odicity. Opium, camphor, aconite, stramonium, alco- 
hol, and many other articles supposed to exercise 
peculiar influences over the nervous system, have long 
been in use. But chloroform is a more recent reme- 
dy belonging to this class, and it seems to promise 
more extensive usefulness than either of the others. 

In such doses as will produce composure and sleep, it 
4* 



82 Lectures on Fever. 

wards off an approaching chill with considerable cer- 
tainty ; and some contend that it possesses in no 
small degree antiperiodic powers. The best effects 
are to be expected from its exhibition by the stomach. 
It sometimes causes vomiting, but even then it is ben- 
eficial, and perhaps only a little less so on that ac- 
count, for vomiting itself is remedial in chill and con- 
gestion, and is one of nature's means for their relief. 
It can scarcely be doubted that the spider's web pos- 
sesses in some degree antiperiodic virtues, but it has 
not proved to be sufficiently active to come into gene- 
ral use. The remarkable effects sometimes reported 
of it have been owing in part, probably, to the influ- 
ences exerted over the mind. Many have been the 
successful schemes of cure founded upon such influ- 
ences alone, but we must not place these among our 
reliable remedies. Faith is worth something in the 
treatment of disease, and physicians are justified in 
its employment, so far as to give patients confidence 
in themselves and their remedies ; but the errors and 
delusions of superstition should very rarely be resort- 
ed to by men of learning and science. 

Purgatives are nearly always necessary in the 
treatment of intermittents, but whenever the fever is 
arrested in its early stage, the purgative treatment 
required is only, in most cases, of the mildest charac- 
ter, and purgative doses need not be often repeated. 
But in case of a longer continuance of the disease, 



Lectures on Fever. 83 

the vital functions become so much disordered, and 
the local lesions so established, as to require a con- 
tinued and persistent plan of moderate catharsis, 
for the double purpose of stimulating healthy glandu- 
lar action, and the evacuation of morbid excretions 
from the bowels. Without the design of producing 
the constitutional impression which is evidenced by 
salivation, mercurial remedies should be employed to 
such an extent as will certainly effect, to a percepti- 
ble degree, both intestinal and hepatic secretion. The 
rest may be done by aloetic and other purgatives, oft- 
repeated, in moderate doses. 

The physician should always be on his guard 
against unnecessary and excessive medication. But 
it is not less important that he should ever bear in 
mind the imperative duty, when called upon for pro- 
fessional advice, to adopt a plan of treatment which 
promises for his patient the most speedy and perma- 
nent relief. The expectant plan taught and practised 
by the French school, aided by the superstitious influ- 
ences of homeopathy, and the prejudices arising from 
the mischievous effects of mercury* quinia, and other 
effective remedies injudiciously used, have had the ef- 
fect to encourage plans of treatment, especially in 
large cities, where fashion governs medical practice as 
it does the cut of the coat, which, without being more 
effective than the infinitesimal system, are without 
the advantages which that system affords in its rigid 



84 Lectures on Fever. 

and formal regimen. These extremes are to be avoid- 
ed in the treatment of intermittent fever, but without 
forgetting that a long continuance of the disease, even 
in its mildest form, always endangers the future 
health, and the life, of the patient. To the motto, 
11 Safely, speedily, and pleasantly" I would have 
you add, thoroughly. 



LECTUEE VI. 



REMITTENT FEVER. 



The term remittent is used to designate a grade of 
periodic fever next higher in degree of violence than 
the intermittent. Both are without doubt the pro- 
duct of a common cause. This may, therefore, be 
considered the same disease which we have been de- 
scribing under another name, proceeding from a some- 
what more intense operation of the febrile cause, and 
consequently exhibiting very much the same pheno- 
mena, only of a more serious character, and requir- 
ing a treatment proportionally more prompt and effi- 
cient. "We have seen that intermittents are generally 
deemed more serious in their character in proportion 
to the shortness of their periods of intermission, quo- 
tidians being more severe than tertians, and these 
more severe than quartans. And it may be consider- 
ed as generally true of quotidian fevers that they are 
of a graver character, pretty much in proportion to 
the length of the paroxysmal period. When this 
period extends over nearly the whole twenty-four 
hours, without sufficient interval between the parox- 



86 Lectures on Fever. 

ysms for the establishment of a complete epyrexia, 
they become remittent fevers. In determining the 
type of the fever something depends, no doubt, upon 
the constitution of the patient, and his predisposition 
to the disease, as well as upon the relative power and 
activity of the exciting cause ; for we find all grades 
and types prevailing at the same time, and in the 
same place, from a septan and quartan ague to the 
most violent remittent fever. 

Another proof that these different types of fever 
are dependent upon a common cause is to be found in 
the fact, that they not unfrequently become merged 
into one another. Thus a quartan may become a ter- 
tian, then a quotidian, and finally assume the remit- 
tent type, and end in the destruction of life, with all 
the appalling conditions attendant upon remittent 
fever of the most malignant grade. Remittents are 
also sometimes, after being partially relieved by treat- 
ment, converted into intermittents ; and I have known 
cases of that troublesome form of intermittent called 
septan ague, to have their origin in severe attacks of 
remittent fever. These were remittents which had 
been relieved, but not cured by partially successful 
treatment. So also do we find these different types 
of fever existing even epidemically, in the same local- 
ity, strangers suffering with the more violent, and the 
native inhabitants with the less violent types and 
grades. While the yellow fever was prevailing with 






Lectures on Fever. 87 

great violence and mortality at the Bay of St. Louis, 
in 1820, and at Pensacola, in 1822, at both which 
places there were two distinct classes of population, 
natives and strangers, the former, or the Creoles, as 
they are called, were favored in the comparatively 
quiet enjoyment of fever and ague, from wilich they 
all recovered ; while the unacclimated inhabitants 
were dying under similar exposure, with black vomit. 
And it sometimes happens, as I can bear witness from 
personal observation, that persons imperfectly accli- 
mated are taken with intermittent fever, while yellow 
fever is prevailing as a fatal epidemic, which after 
two or three paroxysms passes into the remittent type, 
and then very soon takes on all the characteristics 
of the prevailing epidemic, and reaches a fatal termi- 
nation in the usual time, with all the dreadful suffer- 
ings which attend upon the dying hours of the worst 
form of disease which now afflicts the human race. 

Remittent fever is endemic in the West and South, 
and, compared with the intermittent type, is appar- 
ently becoming more common. It prevails most ex- 
tensively and severely in the autumn months, and 
therefore is sometimes called autumnal fever ; but it 
is met with at all seasons of the year. Newly settled 
districts of country, and rapidly improving cities, are 
more liable to its visitations than other places, and it 
is likely to assume a graver character in warm than 
in cold latitudes. But it prevails extensively on the 



88 Lectures on Fever. 

borders of the great lakes of the North, as well as in 
the more sultry regions of the South ; and it often 
proves as fatal in the former as in the latter region. 
Large districts of country in Ohio, Michigan, Indiana, 
and Illinois, have sorely suffered from its ravages dur- 
ing their early history, and the same is true of con- 
considerable portions of the New-England States ; 
while the marshy districts of Southern Louisiana 
have been, under the same circumstances, compara- 
tively exempt from its visitations. It is not, therefore, 
a form of disease in any degree peculiar to the South, 
and there are doubtless extensive regions of southern 
country which have been brought under cultivation 
with less suffering from remittent fever than some 
portions of the Northern States just referred to. The 
northern counties of Mississippi, for instance, have 
been more exempt than the northern portions of Ohio, 
while in progress of settlement. Nor is it by any 
means true, as has been contended by Dr. Drake, and 
others, that southern alluvial lands, abounding in de- 
composing vegetation, and subject to occasional inun- 
dations, are more liable to the ravages of remittent 
fever than the high, dry, sandy and comparatively 
barren districts. The mortuary statistics of Louis- 
iana show a larger ratio of mortality on the high 
than on the low lands ; and this is in accordance with 
the observations of physicians, having reference, how- 
ever, mainly to the recent settlements on the up- 
lands. 



Lectures on Fever. 89 

Although this type of fever is in general most pre- 
valent and fatal in autumn, it often proves to be a 
formidable disease in winter. It is then commonly 
complicated with thoracic lesions, and is particularly 
fatal to old people and children. But in whatever 
organs the local lesions may be established, the dis- 
ease is apt to assume a highly irritative and even in- 
flammatory character when it prevails in cold wea- 
ther. The commonly received theory of miasmatic 
influences, and the current belief that such influ- 
ences are dependent upon high degrees of atmospheric 
temperature, have led many of our profession to the 
conclusion that the causes which produce these at- 
tacks in winter must have had their origin in the pre- 
vious warm season. This would require in many 
cases a period of incubation extending over several 
months ; from August or September even to April 
or May. For if long-continued hot weather be neces- 
sary to the generation of this miasm, we could hardly 
expect it to exist in the spring season to such an ex- 
tent as to cause serious attacks of fever before June 
or July. The conjectural reasoning indulged in on 
this subject sometimes leads to strange inconsistences. 
In winter it is contended that the period of incuba- 
tion is necessarily a long one, because we are bound 
to trace the disease back to a cause which could have 
had no existence after the frosts of September or Octo- 
ber. But in the spring months we are so far removed 



90 Lectures on Fever. 

from this autumnal cause, that we are inclined to 
seek for one of a more recent date, and then we talk 
of the miasms of spring — of vernal fevers arising 
from vernal causes. In the one case, we must allow 
for a long period of incubation, one of four or five 
months ; and in the other, we cannot admit of one 
of as many weeks' duration. This, like many other 
things connected with fever, looks very much like an 
attempt to construct a theory without reference to 
facts. 

Remittents differ from intermit tents chiefly in this 
particular ; they afford no period of a complete suspen- 
sion of the febrile movement, or period of absolute 
apyrexia. But unless diverted from their usual course 
by the influence of treatment, the periods of exacer- 
bation and remission occur daily, with as much regu- 
larity as in quotidian intermittents. As the two types 
differ only in degree, dependent upon the energy of 
the cause, and the impressibility of the patient, we 
must expect to meet with a great similarity in the 
phenomena of both. The conditions precedent, so 
far as we know them, are precisely the same ; and if 
we could rely upon any premonitory signs of attack, 
it would be impossible to determine whether the ap- 
proaching disease would assume the intermittent or 
remittent type. Indeed, after the attack actually 
comes on, it is only by its apparent violence, the well- 
marked characteristics of the different stages of the 






Lectures on Fever. 91 

paroxysm, and, more than either, by the nature of the 
prevailing disease at the particular time and place, 
that we can venture to form a diagnosis, and determine 
whether it is likely to assume the form of an inter- 
mittent or remittent. 

Remittent fever is said sometimes to come on sud- 
denly, and without perceptible premonition. Occa- 
sionally, the first shock of the disease is said to have 
been so sudden and severe, that the victim was pros- 
trated to the earth, and even death, we have been 
told, sometime ensues without time for reaction. But, 
according to my observations in regard to the various 
forms of periodic disease common to this climate, such 
sudden attacks have always been preceded by one or 
more paroxysms, and generally by more than one, of 
a milder character. The cause producing the disease 
does not act thus suddenly upon the system, prostrat- 
ing the powers of life by an impulsive shock ; but it 
does its work of mischief more gradually, often very 
obscurely and insidiously, requiring close attention in 
its early stages to discover the existence of any aber- 
rations from health. In general, these sudden revul- 
sions are reported of cases which occur during the 
prevalence of fatal epidemic fevers, and it is exactly 
in such cases that febrile affections assume the most 
insidious and deceptive character, frequently leading 
the inexperienced greatly astray in regard to the in- 
tensity and danger of the disease. These are im- 



92 Lectures on Fever. 

portant considerations when destructive epidemics are 
prevailing, because it is only in the inceptive stage 
that we can hope, in the present state of our know- 
ledge, to make such curative impressions as will prove 
successful. Not unfrequently it requires great dis- 
crimination to determine upon the adoption of those 
vigorous measures which, while they are essential to 
success, appear to be disproportionate to the mani- 
festations of disease. 

The common symptoms of this form of periodic 
fever in its inception are, unpleasant sensations of 
sinking and depression at the epigastrium, sometimes 
described by the patient as resembling the nauseating 
effects produced by small doses of tartar emetic. This 
sensation is, no doubt, one of a sedative character ; 
and as it is among the earliest symptoms of the dis- 
ease, it may be safe to infer, perhaps, that the cause 
of fever is sedative in its primary effects upon the 
nervous system. This condition of sedation is further 
evidenced, indeed, by a feeling of continued listless- 
ness, by weakness in the limbs, and especially in the 
knees, and by an indisposition to active exercise ; 
sometimes by drowsiness, and even profound and pro- 
tracted sleep. Headache is apt to follow, but it is 
not a constant symptom, or o£ constant intensity. 
Probably its fluctuations in severity correspond with 
the imperfect exacerbations and remissions of the dis- 
ease, in this its forming stage. That headache, w T hich 



Lectures on Fever. 93 

is not un frequently attended also by more or less of 
pain and discomfort in the spinal column, is indica- 
tive of a stage of reaction, is rendered probable by 
the fact that it is commonly accompanied by wakeful- 
ness, succeeding the drowsiness of the stage of seda- 
tion. 

The first paroxysm that occurs of sufficient dis- 
tinctness to enable the patient to see that he certainly 
is attacked by fever comes on with a chill, as in the 
intermittent type, but in general the chill is less vio- 
lent, and less distinctly marked. There may not be 
actual rigor, and shivering and chattering of the 
teeth, and in these fevers of the graver kind there 
generally is not ; but a sensation of coldness so 
slight as might escape observation, were it not of a 
peculiar and unusual character, and attended by other 
signs of disorder. There is a peculiar coldness or 
chilliness affecting the spinal column, and also cold- 
ness of the extremities, and particularly of the fin- 
gers and toes, with blueness of the nails, and also of 
the lips. The countenance, too, indicates by change 
in features and expression, that something unusual is 
the matter with the patient. In a short time these 
sensations begin to alternate with transient flushes of 
heat, so that the patient complains that he is hot and 
cold at the same time. Thirst and dryness of the 
mouth ensue, accompanied by more or less nausea, 
and sometimes by vomiting. The pulse is small, fre- 



94 Lectures on If ever. 

quent, and sometimes irregular. There is pain in 
the head, back, and limbs, with a sense of uneasiness 
and restlessness over the whole body, and the respira- 
tion is hurried and labored. These symptoms, which 
seem to indicate a sort of struggle between the chill 
and the fever — between heat and cold — are soon fol- 
lowed by a state of general excitement, the heat hav- 
ing finally gained the ascendency, although the pa- 
tient is still liable, upon sudden exposure, or contact 
with cold, to more or less of chilly sensations. The 
patient and his attendants are now convinced of the 
great increase of heat, which appears, indeed, to them 
to be greater than it really is. The countenance now 
becomes flushed, the eyes red, the skin dry and hot, 
the pulse full, strong, and frequent, the thirst intense 
and indomitable ; the head throbs with pain, delirium 
sometimes appears, there is tenderness at the epigas- 
trium upon pressure, with nausea and vomiting ; the 
urine is scanty and high colored, the bowels consti- 
pated, swollen, and sometimes tympanitic ; and there 
is a marked diminution in all the secretions. 

This is a brief description of a well-marked parox- 
ysm of periodic fever ; but whether it will close with 
an intermission or a remission, no one can yet tell. 
The physician can only judge of this by the severity 
of all the symptoms, the general character of the 
fevers prevailing at the time, and by whatever he 
may chance to know of the predisposition and suscep- 






Lectures on Fever. 95 

tibility of the patient. If intermittents are the pre- 
vailing type in that locality, he will confidently ex- 
pect that, notwithstanding the severity of the attack, 
the paroxysm will at the proper time wholly subside, 
or intermit. But if the more serious remittent type 
should be prevalent, he would have little or no hope 
of a distinct intermission, unless he may happen to 
know that the patient has secured a partial immu- 
nity from having once had a severe attack of periodic 
fever. When fevers of the graver forms prevail in 
those portions of our country where there are two 
distinct classes of white population, natives and im- 
acclimatized persons, the physician will have reason 
to expect that the former will be much more likely, 
in such an attack as I have described, to have a dis- 
tinct intermission than the latter. And there is a 
class of persons in the South, who occupy a more 
favorable position in this respect than even the great 
bulk of the native inhabitants. These are they who 
have once experienced a severe attack of remittent 
fever. They are apt, indeed, to escape entirely, but 
they are not wholly exempt from fever. When they 
are attacked by the prevailing disease, although the 
early symptoms may appear, as in other cases, grave 
and serious, we may rest assured that the disease will 
prove to be of a yielding character, and if promptly 
met by proper treatment, there will not be a second 
paroxysm. Observation of this fact leads many per- 



96 Lectures on Fever. 

sons to presume upon their partial exemption, merely 
from their long residence in the climate ; but this 
alone, without having once passed through the trying 
ordeal of climatic fever, will not protect them. Many 
lives are lost every year among persons of northern 
birth, in consequence of this mistake. 

But let us return to our subject. The fever being 
of the remittent type, this paroxysm will continue 
from fourteen to twenty hours, when a gradual abate- 
ment of all the febrile symptoms will take place, the 
first signs of which will be observed in the reduction 
of the frequency and force of the pulse, and an abate- 
ment of thirst and febrile heat. These are ordinarily 
followed. by moderate perspiration, and an abatement 
of restlessness. The mind of the patient becomes at 
the same time more tranquil and composed. There 
is a manifest abatement in the severity of all the fe- 
brile symptoms, but not a total suspension of them. 
The patient is much relieved, and feels quite com- 
fortable by contrast — not absolutely — frequently ex- 
pressing his gratification in such manner as to induce 
his attendants to consider him better than he really is. 
This comparative calm, which nature requires after 
an unnatural effort of vital power — a calm not un- 
usual in all the great and disordered exertions of na- 
ture — is a most important period for the application 
of remedial agents, and particularly of that class 
which operate for the prevention of a return of the 



Lectures on Fever, 97 

febrile paroxysm. If these are not applied, and suc- 
cessfully applied, during the remission, there will be 
a renewal of the exacerbation in from one to four 
hours, and sometimes this will be preceded, as before, 
by a chill ; or at least by chilly sensations, attended 
by coldness of the extremities, and particularly by 
coldness of the fingers and toes. This second exa- 
cerbation is almost uniformly more severe than the 
first ; and thus the disease goes on increasing in vio- 
lence from day to day, without observing regular 
periods of exacerbation and remission ; but always 
passing through both, or one whole routine of fever 
and remission every twenty-four hours. 

When the disease is not of such intensity as to de- 
stroy life at an earlier period, a favorable termination 
may be expected on the fifth or seventh day ; but 
should the disease continue unabated, the daily exa- 
cerbations and remissions are apt to return until the 
fourteenth day, although the life of the patient may 
be deemed pretty secure after the ninth. Thus it is 
that all the forms of periodic disease show a tendency 
to observe septenary periods, and the more so the 
longer they continue. It often happens that by ac- 
tive and judicious treatment, we obtain for our pa- 
tient great relief on the third or fifth day ; and yet, 
unless cautiously guarded, he will suffer a considera- 
ble exacerbation on the seventh day. And then, 
again, we may recover our favorable control of the 
5 



98 Lectures on Fever. 

case on the ninth or eleventh day, and even consider 
our patient permanently relieved ; when, much to our 
surprise, we find him again suffering with fever on 
the fourteenth day. And a similar recurrence of the 
disease may take place on the twenty-first and on the 
twenty-eighth days, and so on at intervals of seven 
days, or of some multiple of seven. These returns of 
the fever are apt to be considered and treated as re- 
lapses, when in fact they are recurrences of an un- 
cured periodic fever, in conformity with an inexora- 
ble law of nature ; but it is a law w r hich has as yet 
received no explanation as to its causation. 

This brief description of remittent fever is suited 
more particularly to the milder forms of the disease. 
In many parts of the South it is common, at certain 
seasons, to meet with the disease in a much graver 
grade, and requiring more prompt and active treat- 
ment. This is a grade sometimes called malignant, 
and it gives no promise of spontaneous recovery. If 
the life of the patient is saved, it is by treatment. 
The cold stage, although less marked by the rigors 
and shiverings of an intermittent, continues for a 
longer time, and is painful and serious rather by its 
prolongation than by the degree of coldness, some- 
times ending in death without reaction. The pain in 
the head is often very intense, and the patient com- 
plains of a tightness and rigidity above the eyebrows, 
which he compares to the pressure of a band of iron. 



Lectures on Fever. 99 

The face is either pale and ghastly, or becomes flush- 
ed with a purple or leaden hue, indicating capillary 
congestion, and imperfect decarbonization of the 
blood. The skin is either hot and dry, or moist and 
cool ; the tongue rough and of a purplish color, with 
the mouth moistened with viscid saliva. The coun- 
tenance is expressive of anxiety, agitation, and great 
suffering ; the eyes are often suffused with tears, and 
the conjunctivae bloodshot. Pain in the back and 
limbs is constant, severe and wearisome. Distressing 
nausea is common, with occasional vomiting of viscid 
and acrid secretions. The bowels are constipated, 
but the patient often discharges the watery secretions 
of the large intestines without relief. The action of 
the kidneys is defective, and sometimes wholly sus- 
pended. Delirium is often superadded to all other 
distressing symptoms, and this sometimes amounts to 
maniacal ravings. 

This graver kind of paroxysm having been passed, 
with all its painful concomitants, there comes on a 
remission, which generally occurs early in the morn- 
ing, and is of short duration. The most reliable in- 
dication of its approach is to be found in the pulse, 
which becomes less frequent, and fuller. All the 
more distressing symptoms are, indeed, mitigated in 
violence, but another paroxysm quickly supervenes, 
sometimes within an hour; and unless some relief 
be secured by treatment, it will prove to be more 



100 Lectures on Fever. 

painful and distressing than the previous one. The 
stomach will now be likely to show increased signs 
of disorder, while the pain and constriction of the 
head may be lessened. The extremities become cool 
— sometimes quite cold — to the touch, while the pa- 
tient complains of heat, and is impatient of warm 
applications to the surface. There is cutaneous con- 
gestion, cold sweating, and comparative insensibility 
of the skin, and also excessive thirst. Great restless- 
ness exists without acute pain, and wakefulness with- 
out mental excitement ; and there is evidently much 
suffering without the ability to designate any particu- 
lar location of pain. 

The remission comes again, and almost invariably 
in the early morning hours. After turning and toss- 
ing during the livelong night, racked with indefina- 
ble pains, and tormented by restlessness and inability 
to sleep ; after having been kept half-delirious by 
fever, and perhaps been constantly vomited and 
purged by injudicious medication ; the patient gains 
a partial respite from suffering as morning approaches, 
and exhausted nature finds repose in sleep. There is 
then at last a remission of the fearful disease. The 
nurses, exhausted by labor and watching, gladly avail 
themselves of this opportunity to rest, and at such a 
critical moment, unfortunately, the physician is likely 
to be absent or asleep. The period of remission in 
such a case is always imperfect, and of short duration. 



Lectures an Fever. 101 

The physician returns to his patient to find him in 
the midst of another paroxysm ; and this differs from 
the last mainly in the fact, that it is of still greater 
violence. The various local lesions with which the 
disease has become complicated are all the more for- 
midable from the manifest exhaustion of the vital 
powers of the system. 

We must now expect, that death will speedily fol- 
low, or that there will be a long and tedious continu- 
ance of the fever, under the retroactive influence of 
the local lesions which have been produced, with oc- 
casional periods of partial relief, but with repeated 
relapses and backsets, ending perhaps in final recov- 
ery, but with more or less of chronic congestion and 
hypertrophy of the viscera, which are troublesome 
through life. A great variety of names have been 
applied to the disease taking this prolongated course ; 
but when death ensues, on or- about the fifth day, it 
has been commonly called malignant fever ; which 
name Sydenham considered, in his time, to be more 
destructive to human life than gunpowder. This con- 
stantly varying nomenclature is well calculated to 
lead physicians fatally astray in the treatment ; and 
it can only be useful as an apology to the public for 
the loss of patients. My belief is, that the character 
of the disease has undergone little change since the 
time of Hippocrates. Xames alone have changed. So 
far as I am capable of judging of these things from 



102 Lectures on Fever. 

my own observations, it certainly is true that no ma- 
terial change has occurred in the character of this 
grave form of fever, since I first became familiar with 
the disease, as it prevails in the South, in the sum- 
mer and autumn of 1819. I had much to do with it 
at that time, and have seen many cases every year 
since, without being able to discover any important 
changes, except as the disease varies in intensity in 
different years and cases ; nor am I convinced that 
the indications of cure are different. Like plague, 
small-pox, measles, etc., this form of fever is a specific 
disease, governed in its etiology and pathology by 
fixed and immutable laws. Such it probably ever 
has been, and such it probably ever will be, whatever 
may be the names by which it may be called. 



LECTUKE VII. 



REMITTENT FEVEE. 



Authors agree in the opinion that remittent fever is 
materially influenced in its character and severity by 
the season of the year, as well as by the locality in which 
it prevails ; but it is acknowledged to be most com- 
mon and violent in autumn. For this reason it is not 
unfrequently denominated autumnal fever, or autum- 
nal bilious fever. It is generally conceded, also, 
that this form of fever sometimes prevails somewhat 
extensively both in spring and summer. But writers 
are apt to take little notice of the fact, that remittent 
fever prevails also in winter, and sometimes extensive- 
ly. These eases, however, in general, as I have be- 
fore remarked, are attributed to the influence of 
causes originating and acting upon the system in au- 
tumn, and are, therefore, still spoken of as autumnal 
fevers. I am of the opinion, however, as you are all 
aware, that the cause of periodic fever, whatever may 
be its source and character, originates and acts upon 
the system at all seasons; although it is doubtless 
true, that it prevails in greatest intensity in summer 



104 Lectures on Fever. 

and autumn ; and, considering all the circumstances 
of the case, I can perceive no better reason for at- 
tributing the fevers which prevail in winter to the 
causes originating in autumn, than for assigning the 
fevers of spring to the causes originating in the win- 
ter season. To be sure, there is a hypothesis in re- 
gard to causes, which requires the aid of a higher de- 
gree of heat than prevails in winter, but while noth- 
ing is settled in regard to the character of this cause, 
this should have little or no influence with us, espe- 
cially when we are constantly observing its effects, 
and such effects as we have every reason to believe 
follow as closely upon the action of the cause in win- 
ter as at any other time, the predisposition of the 
patient being the same. 

But it is by no means uniformly true, that remit- 
tents assume their most violent grade in the autumn 
season. Occasionally it happens that autumnal fevers 
are very mild and tractable. Of late years, particu- 
larly, there have been epidemic remittents in the 
South of this mild grade, proceeding to a favorable 
termination in three to seven days, and attended by 
no other inconvenience, scarcely, than what arises 
from the troublesome pains which attend upon all fe- 
vers ; yielding to the mildest remedial measures, and 
sometimes coming to a favorable termination even 
without medication of any kind. It may, therefore, 
be received as true, that the remittents of autumn are 









Lectures on I 1 

not only, in general, of a more violent grade than 
se prevailing at other Be f the year, but that 

they are also, sometimes, milder and more tractable 
than any other. 

Xjw, as the different seasons give rise to remittents 
liferent degrees of severity, so are they marked 
also with a tendency to different local lesions. In au- 
tumn the prominent local lc re those of the liver 
and stomach, notwithstanding that the derangements 
of the early stage appear to be mostly of the brain 
and nervous system. During the forming stage of 
the disease, and all the first well-developed paroxysm, 
the patient suffers with pain in the head and eyes, ex- 
tending also through the spinal column and the Km 
and it is upon the partial subsidence of these, when 
the vascular and secernent systems become involved 
in the diseased action, that gastric symptoms become 
distressing, the hepatic function disordered, and the 
secretions increased or diminished, according to the 
degree of febrile excitement. All the abdominal 
cera suffer more or less derangement, dependent pi 
ably upon the irritation and congest] >n existing in the 
several organs. And this form of attack is more il- 
lustrative than any other of the principle sc jly ad- 
vocated by some modern writers, that fever affc 
first the nervous and secondarily the vascular system. 

The local lesions caused by autumnal fever, then, 
are mostly abdominal ; but the lungs are peculiarly 
5* 



106 Lectures on Fever. 

subject to engorgements in all the various forms of 
periodic fever, and especially in the cold stage. But 
while, like the cerebral derangements, these thoracic 
engorgements give way in the autumn to the more 
distinctive lesions in the abdominal viscera, in the 
winter, when the air is cold and the weather variable, 
when the pulmonic sympathies with cold extremities 
and suppressed perspiration prevail, these primary 
congestions are apt to become persistent, and the 
prominent local lesions are, therefore, within the tho- 
rax. The fevers of spring partake more or less of the 
characteristics appertaining to those of winter, accord- 
ing to the peculiarities of the weather, and the nature 
of the epidemic influences that may be prevailing. 
But as the heats of summer become more constant, 
the pulmonary irritations are lessened in their severity, 
and although still observed in the chill, and inceptive 
stages, they give way again to more potent influences, 
and we have the predominance of the abdominal 
lesions, as in autumnal fever. 

But whatever may be the seat of the prominent lo- 
cal lesions, unless the disease be promptly subdued, 
serious congestions and irritations of the mucous tis- 
sues will ensue, causing prostration of nervous energy, 
and tending toward a prolongation of fever, which 
may become in time wholly symptomatic of these sec- 
ondary affections. The term typhoid, as now used, is, 
I believe, principally applied in this country to desig- 



Lectures on Fever. 107 

nate these protracted cases of remittent fever ; and I 
have serious doubts whether, after all that has been 
said about typhoid fever as prevailing and increasing 
among us, there is any other form than this which,' 
whatever else may be said of it, is certainly not new. 
To my certain knowledge it has prevailed just in its 
present form for full forty years. Barnes have chang- 
ed, as I told you yesterday, but the fever has not 
changed. The disease, in this stage, is now called 
typhoid fever, or typhoid pneumonia, according to 
the locality of the local lesions. The adjective select- 
ed I consider to be an unfortunate one, because, like 
the term debility, which has caused the death of mil- 
lions, it leads to the adoption of excitant treatment 
prematurely, and sometimes even while the periodic 
nature of the disease requires active efforts for its re- 
lief. But I shall have more to say upon this subject 
when I come to treat of enteric fever. 

The morbid appearances after death in remittent 
resemble those in intermittent fever. Structural de- 
rangements exist in the highest degree, of course, in 
those organs and tissues which have been the seat of 
the most serious local affections ; and yet it has been 
found, as is stated by some authors, that fatal, and 
therefore severe, cases of remittent fever have occurred, 
which show no signs, upon post-mortem examination, 
of any considerable local lesions, which could by any 
means account for the death of the patient. Even 



10S Lectures on Fever. 

cases of death preceded by strong indications of cere- 
bral affection, have presented a sound and healthy- 
state of the brain and its membranes. In other cases, 
physicians have been surprised to find the abdominal 
or thoracic viscera equally exempt from morbid ap- 
pearances. And it often happens, that when the 
bodies of such persons have been brought upon the 
dissecting-table for anatomical instruction, no one is 
able to discover what was the cause of death. It was 
my custom for many years to make post-mortem ex- 
aminations of such cases whenever permission could 
be obtained to do so ; and it has seemed to me very 
extraordinary, after carefully watching the course of 
the disease, to find the organs most seriously implicat- 
ed showing no commensurate appearances of disease. 
This is a striking commentary upon the now popular 
French doctrine, which teaches that fever is always 
symptomatic of some local affection. And it seems 
to me to afford strong support to that other less pop- 
ular but more reasonable doctrine, which considers 
fever an idiopathic and constitutional disease, except 
when caused by some clearly defined local affection 
previously existing. 

In gastric or gastro-enteric fever, the stomach and 
some portions of the intestinal canal exhibit signs of 
inflammation, but more commonly of congestion in 
the larger blood-vessels, and sometimes there is a 
thickening or ulceration of the mucous coat. But in 



Lectures on Fever. 109 

fatal cases of gastritis, whether proceeding from fever 
or other cause, I have often been surprised to find 
such small signs of inflammation in the coats of the 
stomach. Frequently a slight thickening of small 
portions near the pyloric orifice only appear, with 
slight redness and turgescence. In some cases of evi- 
dent hepatic disorder, the liver, and often the spleen 
also, are found to be enlarged by reason of vascular 
engorgements, and sometimes both organs exhibit 
signs of inflammation. The capillaries of the brain, the 
spinal marrow, and especially of their investing mem- 
branes, are sometimes found congested, in cases which 
have shown strong symptoms of cerebral disorder ; but 
I apprehend that a majority of cases of cerebral de- 
rangement in fever, are of an irritative and not an in- 
flammatory character. Many times, cases of fever 
with great vascular excitement are called inflamma- 
tory fever ; and yet there is, after death, in most 
cases, no evidence to be found of the preexisting in- 
flammation, and sometimes no sign of it can be found 
in any particular organ. 

These are remarkable discrepancies ; and when we 
consider the fact, that the disease always gives evi- 
dence of a general, constitutional derangement, affect- 
ing, at the same time and almost equally, every por- 
tion of the body, they afford us strong reasons for be- 
lieving that fever, at least in its early stages, is essen- 
tially a nervous disease, affecting especially the 



110 Lectures on Fever. 

ganglionic system of nerves, which is supposed 
to preside over involuntary motion, including, of 
course, circulation, respiration, nutrition, and di- 
gestion. These vital functions may become so disor- 
dered by nervous influences, as to cause death with- 
out any appreciable change in the structure of 
any organs of the body; and the violent derange- 
ment which the involuntary functions receive imme- 
diately upon the accession of the febrile paroxysm, 
would seem to be sufficient evidence of nervous agen- 
cy. If it can thus be shown that the primary action 
of the febrile poison be upon the nerves which gov- 
ern involuntary motion, and that the subsequent vas- 
cular excitement is caused by this disturbed action of 
these nerves, producing local lesions or not, according 
to the length of time the disease continues, and the sus- 
ceptibility of particular viscera, we cannot be far from 
the truth in declaring fever to be, especially in its early 
stages, a purely nervous disease ; and this view will 
receive confirmation also, as you will perceive when 
I come to speak of the treatment of fever, in the ac- 
tion of remedies. In a former lecture I stated the 
fact, that this theory of fever was long ago advocated 
by distinguished men, and it is quite unaccountable 
how their successors could have ever lost sight of it. 
It can only be attributed to the prevailing rage for in- 
novation, and to the ambition of authors and teachers 
to acquire distinction by originating new theories to 



Lectures on Fever. Ill 

bear the names of the inventors. In the history of 
mankind, this ambition of distinguished physicians 
has only been equalled by that of pretended religion- 
ists, to become the promulgators of novelties in the 
Christian system. But there is this difference in the 
two subjects : medical knowledge is progressive and 
improvable, but the religious system was promulgated 
in a perfect form, and all innovations must, of course, 
be false. 

The remedies employed in the treatment of remit- 
tent fever are many and various, and the different 
methods of using them are quite as many and various ; 
making it quite difficult for a young physician to de- 
termine the proper means to be employed for the ac- 
complishment of particular results. But there has 
been a tendency, of late years, to simplify prescrip- 
tions in the treatment of all diseases, leading to the 
use of single, uncombined remedies, and dispensing 
with many adjuvant articles in our very redundant 
materia meclica. In the treatment of fever especially, 
the number and variety actually used by some physi- 
cians of large experience is surprisingly small, and 
the doses of each are, in general, also small. These 
facts are well worthy of your consideration ; for in 
few other things are young physicians more likely to 
err. As the style of young writers abounds in exple- 
tives and superlatives, so the practice of young physi- 
cians is characterized by heroic doses and adjuvants. 



112 Lectures on Fever. 

The first remedy I shall speak of in this connection 
is — 

Bloodletting. — Many disputes have arisen as to the 
indications for its use in fever, and some have even 
condemned it altogether ; although all agree that it 
exercises a powerful influence over vascular derange- 
ments, which are ever present and leading character- 
istics of fever. On account of a popular prejudice 
which prevails to some extent against the loss of 
blood, and the trouble of performing the operation, 
physicians are no doubt sometimes willing to dispense 
with bloodletting, when they feel assured that it would 
prove useful. But during the prevalence of fevers of 
a high grade, we can never foresee in the early stage 
to what extent of severity the disease may go ; and 
it is our duty in all cases to adopt the most certain 
means of relief. The remittent is a more grave and 
serious type of fever than the intermittent, and sub- 
ject to more violent and dangerous local lesions; we 
might therefore expect that it will require, particu- 
larly in southern latitudes, more active depletory 
measures. If it be no uncommon thing, therefore, as 
I have stated in a former lecture, to derive benefit 
from the use of bloodletting in intermittents, much 
greater benefit may be expected to result from it in 
remittents ; and we find in most parts of the country, 
and by most physicians who use this remedy at all, 
that it is resorted to much more frequently in the lat- 



Lectures on Fever. 113 

ter than in the former type. It may be considered a 
more important remedy in the South than in the 
North, and, according to all my observations, it is not 
less easily borne, or a less efficient remedy in cases 
of Southern than in those of Northern men ; although 
the latter are more likely to require its application, 
because the disease is apt to attack them with greater 
yiolence. It doubtless is true, however, in regard to 
classes of mankind, that persons of Southern birth, 
and negroes, do not require the loss of so much blood 
as white persons of Northern birth and habits. But 
under the same conditions of the system, the remedy 
is of equal importance to all. 

Whenever the first distinct paroxysm is at all vio- 
lent, and attended by a concentration of morbid ac- 
tion upon some vital organ, threatening with serious 
lesion the brain, stomach, liver, or lungs ; and parti- 
cularly when the chilly sensation with which the par- 
oxysm begins becomes protracted into the hot stage, 
which may always be considered evidence of serious 
internal congestions, bloodletting is not only a useful 
but an important remedy ; and not unfrequently it is 
essential to the preservation of life. Even when not 
so important as this, its employment in the early stage 
often affords us an advantage over the disease, which 
can with equal certainty be obtained in no other way. 
It not only equalizes the circulation of the blood, and 
subdues vascular excitement, but guards the vital or- 



114 Lectures on Fever. 

gans against those serious and sometimes lasting local 
congestions which, if they do not destroy life, pre- 
vent a perfect cure of the disease. In the more vio- 
lent cases, it is often advantageous to resort to blood- 
letting a second and even a third time, and particu- 
larly in plethoric subjects threatened with serious 
local congestions and inflammations. General blood- 
letting has many advantages in the early stage of 
fever over local, and it is best performed by opening a 
vein in the arm. It is comparatively of little use to 
apply cups and leeches to the head, stomach or chest, 
when the symptoms indicate the existence of a state 
of great general excitement ; but when this has been 
in some degree relieved by bloodletting, and other 
remedies, and the local affection still continues to an 
inconvenient extent, then topical bleeding may be re- 
sorted to with great good effect. And this good effect 
will not in such case be wholly confined to the local 
affection ; but it will readily be perceived that its 
tendency is, to reduce the force and frequency of the 
pulse, and by consequence the febrile excitement. 
When cups or leeches are used, they should generally 
be applied in the neighborhood of the local affection ; 
but sometimes the effect is -very striking when they 
are applied to the spine, over that portion whence the 
nerves issue which are distributed to the diseased or- 
gans. 

In the treatment of remittent fevers of a grave 



Lectures on Fever. 115 

character, it is an object to make a favorable impres- 
sion in the early stage, by which the disease is con- 
verted into a comparatively mild grade ; and there is 
no remedy more effective for this purpose than blood- 
letting. Unless such impression be made, each suc- 
cessive paroxysm renders the disease more serious. 
The remissions become less distinct, and of shorter 
duration, the exacerbations less marked and decided, 
and the febrile excitement less prominently developed. 
It is at this stage, and under these circumstances, that 
the disease is apt to take the name of congestive fever. 
The pulse is neither so full nor so frequent as before, 
and the skin is frequently moist and cool. There may 
be pain in the head still, but without the red cheek and 
the blood-shot eye. These have given place to a dull 
and purplish color, indicative of a sluggish, capillary 
circulation. A dull, heavy, restless feeling succeeds 
acute pain, and the secretions of the liver and kidneys 
are lessened or suspended. Thus a disease which the 
physician would in the early stages have pronounced 
inflammatory fever, becomes by degrees congestive ; 
and, finally, according to modern ideas, typhoid. The 
difficulties in the way of a speedy cure are greatly in- 
creased by these progressive changes, against which 
the patient can only be protected with any degree of 
certainty, by a pretty free use of bloodletting in anti- 
cipation of them. 

Tartar emetic is the agent next in importance in 



116 Lectures on Fever. 

the work of reducing tlie force of exuberant excite- 
ment. In a large majority of cases the physician is 
called in during the exacerbation of fever, and his 
first object is to secure an early remission, that he 
may be able to apply antiperiodic remedies. By the 
proper use of bloodletting and tartar emetic he is not 
only enabled to do this, but he will also guard his 
patient against those local lesions which have to be 
obviated to insure recovery. Like bloodletting, tar- 
tar emetic is directly sedative, acting upon the vascu- 
lar, through the medium of the nervous system. The 
excitement of the capillary circulation is so far re- 
duced by the influence of these sedative remedies 
under judicious management, as to facilitate the pas- 
sage of the blood through the proper channels, and 
thus prevent those engorgements and hypertrophies 
which become troublesome causes of prolonged febrile 
action, and equally troublesome sequelae of the dis- 
ease. While the action of tartar emetic is some- 
what less prompt and less agreeable than bloodletting, 
it is, by its frequent repetition, and persistent influ- 
ence, in many cases, the more efficacious remedy of 
the two. In many cases, however, the physician 
finds it advantageous to resort to both, the tartar 
emetic serving to perpetuate the sedative influence 
caused by the loss of blood. 

Physicians are not fully agreed as to the best meth- 
od of administering this remedy, and particularly as 






Lectures on Jb ever. 117 

to the necessity of giving it to the extent of causing 
nausea, to secure the benefit of its sedative power. 
But my own observations lead me to believe that it 
is sedative in its effects under all circumstances, and 
to the extent that it produces any effect whatever. 
If given in doses insufficient to produce nausea, the 
sedation may not be very apparent ; but when given 
in doses decidedly nauseating, and repeated to keep 
up the nausea for any considerable time, the sedative 
effect becomes very decided. We have then the dou- 
ble advantage of the directly sedative operation of 
the remedy, and the sedative effect of the nausea ; for 
it is well known the medicines which produce nausea 
are sedative by reason of the nausea, although there 
are many nauseant remedies which do not act as di- 
rect sedatives. In treating an active exacerbation of 
fever, therefore, I recommend that tartar emetic be 
used to the extent of producing and sustaining a con- 
siderable degree of nausea. 

The plan of administration which I have considered 
best is the same that I have recommended in my lec- 
tures to you, for many other active medicines, name- 
ly, to begin with small doses, and to increase the quan- 
tity as the patient is found to tolerate or require it. 
But in deciding upon the use of tartar emetic, and 
upon the proper dose in any particular case of fever, 
we must always consider the extent to which the sto- 
mach is involved by the local determinations of the 



118 Lectures on Fever. 

disease. Should hyperemia of the mucous mem- 
brane of this organ exist, attended by nausea and 
vomiting, and by tenderness at the epigastrium, as in 
gastric fever, it may be injudicious to give tartar 
emetic at all ; and it must, in cases exhibiting any of 
these symptoms, be given, if given at all, very cau- 
tiously and sparingly. This is one great disadvan- 
tage in the treatment of gastric fevers, and it obliges 
us to rely more upon depletive and refrigerant reme- 
dies. I consider it proper, therefore, to use both gen- 
eral and topical bloodletting more freely in all those 
cases of fever which threaten at an early stage parti- 
cular gastric complications ; and especially when such 
form of fever is epidemic. One or more free bleed- 
ings from the arm in the first stages, and the applica- 
tion of cups or leeches to the epigastrium at a later 
period, are found to be the most effectual antidotes to 
nausea and vomiting. 

The difficulties in the way of using tartar emetic 
in the gastric form of remittent fever, which is in gen- 
eral the most violent and fatal of all the forms of 
fever, renders it very desirable that some substitute 
sedative of equal power should be discovered. The 
veratrum viride has lately been highly recommended, 
and it appears to have remarkable sedative power, but 
I fear it will be found to be too irritating to promise 
good results in cases of gastric inflammation. In a 
case in which I have seen it used lately, the patient 






Lectures on Fever. 119 

compared its effects to those of molten lead, and the 
dose was not repeated. It has been suggested that 
the hydrocyanic acid, or some of its compounds, or 
the sulphuretted or carburetted hydrogen, may be 
brought into common use as sedative agents. The 
carbonic acid gas is now used to some extent ; and its 
value and reputation would be increased, I suspect, if 
it were more commonly used without loading and em- 
barrassing the stomach with undue quantities of fluid, 
as is too often done. 

Upon these two measures, therefore, bloodletting 
and the exhibition of tartar emetic, you may place 
your main dependence in the treatment of an exacer 
tion of remittent fever ; but substituting some other 
sedative for the antimony, when there are serious gas- 
tric lesions. With the exception of counter-irritants, 
with a view to equalize excitement, and refrigerants 
to reduce the preternatural heat, little else need be 
done in the way of treatment until the period of re- 
mission. The various forms of bathing which I have 
heretofore described to you, are valuable remedies ; 
but I doubt whether any other means of refrigeration 
is equal to that of the cold water enema. I have 
seen patients submitted to the influence of the exter- 
nal application of ice and iced water, bathed with 
cold or warm water from head to foot, plied for hours 
with cold acidulated and effervescing drinks, and 
treated in every conceivable way for refrigerant effect 



120 Lectures on Fever. 

for hours together, without one half the relief and 
comfort to be derived from a single pint of cold water 
injected into the rectum. 

The sinapism is, perhaps, the most valuable coun- 
ter-irritant, but in a state of high febrile excitement 
it should only be used to equalize the circulation. At 
a period when this excitement has been partially sub- 
dued, and the patient is suffering from serious local 
congestions, mustard applied to the surface exten- 
sively and repeatedly becomes a most important and 
powerful remedy. Blisters are also valuable under 
similar circumstances, and in some cases these possess 
an advantage in the discharge of serum ; but mis- 
takes may be made in applying them during the ex- 
citement of fever, over some organ suffering from ac- 
tive inflammation, by which this evil is increased. 
Yesication by the use of hot water, sometimes resort- 
ed to in fever and cholera, is liable to the same objec- 
tion. Indeed, this application, as I have known it 
used, appears to be a refinement of cruelty in prac- 
tice, at which human sympathy revolts. And the 
same maybe said of the use of the red-hot iron drawn 
along the spinal column, when the effect sought to be 
produced could more certainly be attained by other 
less cruel and repulsive means. It is a sad mistake 
sometimes made to adopt, in a fit of despair, the 
most cruel tortures for a dying patient, in the hope of 
securing some kind of equivocal eclat from bystand- 



Lectures on Fever. 121 

ers. Every well-meaning physician feels the duty 
incumbent upon him to so prepare himself by pre- 
vious study and reflection, as to be able to meet the 
great emergencies of practice in the spirit of the 
philosopher and the Christian. This is one of the 
high responsibilities of our noble profession. 



LECTURE YIIL 



REMITTENT FEVEK. 



In my last lecture I remarked upon the febrile ex- 
acerbation, or stage of excitement, and spoke of some 
of the remedies employed with a view to moderate its 
force, shorten the period of its continuance, and pre- 
vent the establishment of local lesions as one of its 
consequences. The next object of attention is to 
watch with all vigilance for the period of remission. 
And there is no danger of disappointment ; for, if the 
patient do not die in the paroxysm, a remission is cer- 
tain to follow in the course of twenty-four hours from 
the commencement of the paroxysm. Sometimes it 
occurs at one hour, and sometimes at another, but in 
cases of greatest violence and danger, it generally 
happens early in the morning. Relief of suffering is 
obtained, as I have before remarked to you, at the 
dawn of day, or even a little earlier, when the patient 
and nurses are apt to be asleep, and the physician 
absent. 

Paroxysms of remittent fever generally come on 
early in the day. In the more violent grades, the 









Lectures on Fever. 123 

period of nervous depression is of shcflrt continuance, 
the exacerbation quickly follows, and it increases in 
severity during all the day. After night, there is 
oftentimes an abatement of suffering, with a reduction 
in the force but not in the frequency of the pulse. 
Some time between three and six o'clock in the morn- 
ing, the careful observer will perceive that the pulse 
is becoming somewhat less frequent also ; and this 
will be the first absolute sign of the approaching re- 
mission. It will very soon be followed by an abate- 
ment of heat, pain, nausea, and restlessness, and after 
a while by imperfect and disturbed sleep. After the 
patient has been annoyed by treatment and tortured 
by pain, restlessness, and wakefulness, until well-nigh 
exhausted, no one will seem to doubt, that a little 
rest is now, of all things, just what the patient most 
requires. The class of remedial agents hitherto em- 
ployed, are now no longer applicable to the case, and 
all active treatment is likely to cease, at the very mo- 
ment when it is most important and valuable. 

At the risk of a little tedious repetition, you must 
permit me to urge this point upon your attention. I 
have lived for many years in the midst of this de- 
structive disease, and I have seen it day by day, and 
year by year, sending my fellow-beings down, prema- 
turely, to the silent tomb. I have known hundreds 
to die from the milder, and hundreds to recover from 
the severer grades ; but upon no one point or condi- 



124 Lectures on Fever. 

tion have so many of the cases turned, whether for 
the better or for the worse, as upon this which I am 
now considering — the attention or neglect of the pa- 
tient at this critical period of time, early in the morn- 
ing. If, therefore, you are to engage in the practice 
of your profession with the honesty of purpose which 
characterizes the actions of good men, I must solemn- 
ly warn you, that w r henever it falls to your lot to be 
called upon to treat cases of remittent fever of a vio- 
lent grade, you can hardly expect to discharge your 
duties properly, without carefully preparing for this 
contingency, or without standing by the bedside of 
your suffering patient while the day is dawning. 

The period of remission in such cases comes on 
rather suddenly, and it is short and delusive. It is, 
therefore, always difficult to adopt such precautions 
as will certainly secure the proper attention. Yery 
often you will find it of little avail to prescribe active 
remedial measures to be used at a time when, after 
long suffering, the patient is partially relieved and 
enabled to enjoy rest and sleep. Nurses will admin- 
ister remedies freely while the patient is undergoing 
severe suffering, but when he is relieved of this, few 
of them can be persuaded that it is the proper time 
for active treatment, and thus life is often sacrificed 
to inattention and neglect. 

The treatment to be adopted in this remission of 
fever is now very different from that of many years 






Lectures on If ever. 125 

ago, when I first entered upon the practice of our 
profession. It is at once more simple, effective, and 
intelligible. The system, reacting in a violent man- 
ner from a state of morbid depression, has been sorely 
exercised by nervous and vascular excitement, impair- 
ing and shattering all the normal energies, now ar- 
rives at a period of comparative rest. This is not to 
be considered a subsidence of disease, but only a tem- 
porary exhaustion of excitability, a state of recupera- 
tion, preparatory to another morbid effort to rid the 
body of the mysterious and unknown causes of such 
frightful disturbance. Xature, after all great and 
preternatural exertions, is apt to seek temporary re- 
pose, and in this instance that repose invites the inter- 
position of such remedial measures as will prevent a 
succeeding and more dangerous paroxysm. Until 
the discovery of quinia and the antiperiodic power of 
arsenic, no certain means of doing this were known 
to the profession ; and these fevers ran their course to 
a favorable or an unfavorable termination, with very 
little treatment that could be considered decidedly 
curative in its character, and none that was antidotal 
to the mysterious principle of periodicity. Cinchona 
had been made available in this respect in the treat- 
ment of intermittents, which afforded a respite suffi- 
ciently long in their intermissions to enable the phy- 
sician to bring the patient under its peculiar influence ; 
and thus this form of fever was arrested and cured by 



126 Lectures on Fever. 

it. But the remittent type did not, in general, afford 
time for the accomplishment of this object, and the 
stomach, in most cases, being in an irritable condition, 
could not be made to retain and digest a sufficient 
quantity in the one, two, or three hours during which 
an abatement of febrile excitement existed, to pre- 
vent its return. In many cases, the attempts which 
were made to accomplish this object, by the exhibi- 
tion of bark in substance, resulted in a distressing in- 
crease of gastric disturbance, and an unfortunate 
exhaustion of vital power. 

Now, what the discovery of cinchona was to inter- 
mittents, the discovery of quinia is to remittents. 
What was done by the former in a whole day, may 
be done by the latter in a single hour, giving us all 
the advantage of effective treatment, if promptly and 
judiciously applied, in the case of a short remission, 
that we had in the former case in a long intermission. 
It was not often deemed necessary, in the apyrexia of 
intermittents, to subject the system to that full seda- 
tive powder of bark which has been called cinchonism, 
and many physicians, I suppose, had never witnessed 
it ; but in the more urgent case of remittent fever, as 
now treated, the sedative power of bark and its salts 
is often observed. Indeed, there is no certainty of 
immediate relief without it, especially in the more 
violent forms of the disease. This, then, is what you 
are expected to accomplish for your patient during 






Lectures on Fever. 127 

the first remission that occurs after you take the case 
in charge, however short and imperfect that remission 
may be. For this purpose I have advised you to be 
found standing at his bedside at the critical hour, to 
determine, from the signs of abatement in the febrile 
action, and especially from the reduction in the force 
and frequency of the pulse, that the remission is at 
hand. It is not necessary to wait until the remission 
is full and complete, for in both the intermittent and 
remittent types, quinia in full doses hastens on the 
period of apyrexia, if given upon the first appearance 
of abatement in the febrile action, just as certainly 
as it increases it while the exacerbation is cumulat- 
ing. This distinction is important, while urging on the 
treatment. 

There is much difference of opinion in regard to 
the proper quantity of quinia to be given in such 
cases, and frequently it is quite difficult to determine 
this, some persons undoubtedly requiring more than 
others under similar conditions. What you have to 
consider is, that your success, and sometimes the life 
of your patient, depend upon the establishment of a 
state of cinchonism ; and upon your maintaining it 
until all danger of a return of the paroxysm is over. 
I have rarely given more than ten grains for the first 
dose, but when the effect is not decided, I have gen- 
erally followed it by five more, and sometimes by ten, 
in the course of an hour. When the disease is so vio- 



128 Lectures on Fever. 

lent as to give reason to apprehend a fatal issue, it 
becomes a matter of such great importance to quinin- 
ize the patient promptly, that it is always better to 
take the risk of too much than too little ; for in many 
cases life turns upon the question of another paroxysm. 
Several considerations must be constantly borne in 
mind, however, in the administration of quinia in this 
disease. 1. It is stimulating and injurious while fe- 
brile action continues, unless given in quantity suffi- 
cient to secure a constitutional sedation. 2. When 
given in such quantity, and this effect secured, the 
sedation may be sustained by much smaller doses 
than were required to produce it. 3. It is generally 
necessary to keep up and sustain this sedative action 
of the quinia for some two or three hours beyond the 
usual period for the return of the paroxysm. 4. The 
quinia treatment must be repeated just before the 
next, and indeed, before several successive paroxysmal 
periods, to protect the patient against a recurrence ; 
but the quantity used for this purpose may be lessen- 
ed from day to day. In violent cases, or during the 
prevalence of an epidemic, it is sometimes advisable 
to continue this precautionary treatment until after 
the seventh day, the first septan period, when there 
is generally a disposition to a repetition of the parox- 
ysm. This is mainly the course to be pursued in the 
use of quinia ; but it is proper to remark, that each 
and every dose may be rendered more efficient, and 






Lectures on Fever. 129 

the size of it may, indeed, be reduced, by the simulta- 
neous use of the arsenous acid in substance. And 
when, by some idiosyncrasy, the patient cannot take 
quinia without painful effects, the arsenic may be sub- 
stituted for it, with scarcely less beneficial results. 
The dose may be varied, according to circumstances, 
from one tenth to one fifth of a grain, and repeated 
as quinia is repeated. 

It happens, not unfrequently, that in the most vio- 
lent cases of remittent fever, and especially those 
complicated with gastric lesion, the stomach will not 
retain the quinia in sufficient quantity to produce its 
constitutional effects, and that nausea and vomiting 
follow every repetition of the dose. When this is the 
case, the quinia should be given by enema. Common- 
ly, it requires about three times the quantity that 
would be required if taken into the stomach. The 
medicine should be reduced to a fine powder in a 
mortar, and then mixed in thin starch. Sometimes 
five or ten drops of laudanum are added, the better to 
insure its retention ; but in most cases of this kind in 
which there is much gastric excitement, opiates are 
contraindicated, and it is better to avoid, if possible, 
even this small quantity. If the crystals of the salt 
are reduced to an impalpable powder, the enema can 
generally be secured in its position by pressure upon 
the anus, until the inclination to discharge it passes 
away. Should the experiment fail, it should prompt- 



130 Lectures on Fever. 

ly be repeated, and repeated several times. It is 
rarely ever all discharged, and the portions retained 
after several repetitions will generally prove sufficient. 
Quininization being fully effected, the gastric disturb- 
ance is generally allayed by it, and then the remedy 
may be administered in the usual way. The quanti- 
ty used must be determined by the effects produced ; 
and a physician who has been much in the habit of 
observing the operation of quinia, can hardly fail to 
discover whether the proper amount has been retain- 
ed. But it should always be remembered that much 
smaller doses are required to sustain than to produce 
the necessary constitutional influences. 

Although I do not agree in opinion with those who 
believe, as was formerly believed by many of the bark 
in substance, that the use of quinia is productive of 
serious and permanent injury to the constitution in 
most cases, still I must advise you, that this and all 
other medicines acting specifically upon the nervous sys- 
tem may be used so injudiciously, and in such excessive 
quantities, as to produce the most melancholy results. 
No article of the materia medica is powerful for good, 
that cannot become powerful for evil also ; and we 
have no remedy in use of such active poisonous qual- 
ities that cannot be made harmless by judicious man- 
agement. Take strychnia as an example. In doses 
of a single grain it becomes dangerous to life, but in 
the proper quantity for remedial purposes, it becomes 



Lectures on Fever. 131 

both mild and agreeable in its operation. The seda- 
tion which quinia produces appears to be specially 
operative upon the brain, as evidenced by ringing in 
the ears and partial deafness. Carried only a little 
further and its influence maintained, the eyes become 
affected, and instances are not wanting in which the 
senses of hearing and seeing have been destroyed by 
it. Partial paralysis of some of the limbs has also 
sometimes been produced, and even mental imbecility. 
Tou will not, therefore, be justified in the conclusion, 
because, in a vast majority of cases no harm results 
from the use of quinia, that it cannot be abused, so 
as to cause serious and permanent mischief. 

I would not have you to infer that the course of 
treatment which I have now described is as easy of 
execution as it is simple in description ; and that be- 
cause little medication is advised, little skill is re- 
quired. On the contrary, no one can expect to be 
successful in the application of this practice, except 
he be well skilled in diagnosis and therapeutics. The 
power of quinia over periodicity, especially when aid- 
ed by arsenic, is so supreme that all cases may possi- 
bly be within its absolute control ; but if great dis- 
crimination, care, and skill be not exercised during all 
the paroxysm and remission, such local lesions will be 
formed, probably in the shape of congestions in some 
of the viscera and vital organs, as cannot readily be 
remedied. The fever is gone, perhaps, only to make 



132 Lectures on Fever. 

the evidences of its existence felt in some less tangi- 
ble form. Glandular obstructions are formed which 
are not easily removed. Diseased hypertrophy has 
seized upon certain important organs, seriously de- 
ranging their proper functions. Inflammation of an 
obscure and chronic character has insidiously seized 
upon deep-seated and hidden tissues ; and instead of 
a case of simple fever affecting the system generally, 
the proper treatment of which is comparatively ob- 
vious, you have to contend with a complication of 
diseases, causing prolonged febrile action by their 
irritating influences, the precise character of which it 
is difficult to comprehend, and the successful treat- 
ment of which is often beyond your power. 

Formerly, and before we had it in our power by 
any means then known to arrest the disease in its 
early stages, a succession of daily cathartics was re- 
quired ; not so much to relieve the bowels of ingesta 
or for purposes of depletion, as to purge off the ex- 
cretions which are constantly poured into the intes- 
tinal canal by the exhalents and glandular structures, 
and which become sources of much irritation and 
annoyance, and unless promptly removed will cer- 
tainly lead to dangerous and distressing symptoms. 
The embarrassment occasioned by these accumula- 
tions in the intestinal canal is pretty much in propor- 
tion to the repetitions of the paroxysms, and their 
duration and intensity ; and a similar relation exists 



Lectures on Fever. 133 

between these accidents of the disease, and the local 
lesions which result from it. Neither of these diffi- 
culties are supposed to occur to much extent during 
the remissions. They are caused by febrile excite- 
ment, and therefore the recurrence of the paroxysm, 
as well as its severity and duration, is sedulously to 
be guarded against. If the first severe paroxysm can 
be greatly mitigated in its force by treatment, and if 
its return can be prevented, we have reason to hope 
that these intestinal accumulations are only to a very 
moderate extent ; and that the local lesions caused by 
fever are not numerous, or of a grave character. 
The action of antiperiodic remedies is favorable to 
healthy secretion, and to the peristaltic movement, by 
relieving the system of febrile tension ; and by these 
means alone are the bowels frequently relieved of 
morbid matter, and local congestion and inflamma- 
tion overcome or prevented. 

But whenever it happens, for w T ant of skilful treat- 
ment, that our patient has passed through several ex- 
acerbations and remissions, w T e shall be apt to find 
that the evils alluded to are much increased. Thei*e 
are more intestinal accumulations, and greater and 
more extensive local lesions. From the irritation 
produced by these, the fever has become to some ex- 
tent symptomatic. Cathartics in this case are quite 
as essential as antiperiodics ; and both classes of 
remedies must be used with due regard to the new 



134 Lectures on Fever. 

complications now existing. These will be such, in 
all probability, as to require also the use of alterative 
remedies ; and in the employment of these great care 
must be exercised as to both the time and the man- 
ner. If we attempt by these means to relieve local 
congestion or inflammation, while the whole system is 
in a state of vigorous febrile excitement, tending not 
only to confirm the diseased condition which we pro- 
pose to remedy, but to produce similar morbid effects 
in other organs not yet seriously implicated, we can 
hardly expect our remedies to succeed. The class of 
remedies apt to be preferred is that called alteratives, 
nearly all of which are pretty active excitants, and 
we have no good reason to expect that an excitant of 
any kind will work out its good effects to the extent 
expected, while the morbid condition pervading the 
whole system, as well as the diseased organs requiring 
special relief, is already suffering from undue excite- 
ment. The choice of such time for the exhibition of 
alteratives is injudicious, and does not promise favor- 
able results ; and the attempt to use them may be 
likened to that of an effort to relieve col^ryza by stim- 
ulating sternutatories. 

When we find disease prevailing in the animal 
economy, and are called upon to apply the proper 
remedies, our first object should be to ascertain and 
remove its cause. The febrile action is the cause 
of the condition we are now contemplating, and 



Lectures on Fever. 135 

this being first removed, our second object is the 
removal of the diseased conditions which the fever 
has produced. The proper time, then, for the suc- 
cessful application of alterative remedies in such case 
is after the fever has been subdued ; and you may 
rely on it, that he who attempts the object in view, 
without an observance of this rule of practice, will do 
his work under great disadvantages, if he do not 
entirely fail. 

It is conceded by physicians generally, that the vis- 
ceral disorders resulting from fever are best relieved, 
in a large majority of cases, by the use of mercurial 
remedies. These possess alterative powers to an emi- 
nent degree, and they are made especially valuable 
in the treatment of these local lesions resulting from 
fever, which are supposed to consist mainly of hyper- 
semia of the capillary vessels, causing hypertrophy 
and functional derangement of the diseased organs. 
But unfortunately the members of our profession are 
not so well agreed as to the peculiar method in which 
mercury should be applied for this purpose. In de- 
termining this matter several things are to be consid- 
ered. If a cathartic effect be the object, either dur- 
ing the continuance of the fever or after it has been 
subdued, calomel may be given in scruple doses ; but 
whenever the indications require an alterative effect, 
much smaller doses may be used. I have long been 
in the habit of using calomel in pills of one grain 



136 Lectures on Fever. 

each, one of which may be given three or four times 
a day. Sometimes I have given two grains at a dose, 
and quite as often only half a grain. But whether 
given in large or small doses, I rarely ever, contrary 
to the usual custom, combine it with opium ; nor do 
I allow opiates in any form to be administered, ex- 
cept in cases of great irritation, while my patient is 
under the operation of calomel. 

In this practice I am, perhaps, a little singular ; 
but it has always appeared to me that there is an in- 
consistency in the combination of calomel and opium 
in these cases. The principal benefit to be derived 
from calomel as an alterative is, that it tends to the 
restoration of the impaired or suspended secretions ; 
while the action of opium, as all experience shows, 
is directly the reverse ; so that the one remedy is all 
the while counteracting the proper effects of the other. 
It seems unaccountable, therefore, that the disposition 
among physicians is so prevalent to unite the two 
remedies in the treatment of fever. In the early or 
irritative stage of fever, opium is no doubt a valua- 
ble remedy, and in the present state of our knowledge 
can only be replaced by chloroform, but in this stage 
little use can be made of calomel, except as a mere 
cathartic. But when this stage of irritation is passed, 
and the indications are to relieve hyperemia, and re- 
store secretion, calomel is our best remedy, and al- 
most our sole dependence, while opium, as I have 
before remarked, is contraindicated. 






Lectures on Fever. 137 

The evils of mercurial salivation are also to be con- 
sidered in this connection. This the physician must 
always consider a serious misfortune, as the mischief 
resulting is often incalculable. It is almost invaria- 
bly caused by the use of opium in connection with 
mercury, thus lessening the influence of the latter 
upon the organs of secretion, and concentrating its 
action upon the gums and salivary glands. In almost 
any condition of the system, large quantities of mer- 
cury may be given without danger of salivation, if 
opium be entirely withheld. 

In many cases of glandular obstruction and disor- 
dered function following fever, topical bloodletting is 
of great value. But when we look upon our patient 
as cured, or nearly so, because febrile action has dis- 
appeared, we are apt to feel reluctant to resort to the 
use of a remedy which custom has mostly confined 
to the early stages of the disease, and with some in- 
deed has banished altogether. Should the symptoms, 
however, indicate the existence of congestion or in- 
flammation in any of the viscera, threatening hyper- 
trophy or disorganization, there is scarcely any case 
or condition which more unequivocally requires the 
application of cups and leeches. Next to these the ex- 
hibition of tartar emetic is most effective; and not 
unfrequently, the local excitement being subdued, 
iodine becomes a valuable substitute for mercury as 
an alterative. 



138 Lectures on Fever. 

I ought not to omit, in conclusion, to mention that 
sometimes there is a hemorrhagic tendency in all the 
forms of periodic fever, and more commonly in the 
remittent type. In some seasons and localities it oc- 
curs more frequently than in others, depending per- 
haps upon epidemic influence. When it appears in 
yellow fever, and the stomach becomes a seat of hem- 
orrhagic discharge, it is black vomit. Physicians 
sometimes consider it a critical and beneficial dis- 
charge, and in many cases I have no doubt it is so ; 
but unfortunately it is not always subject to remedial 
agents, and proves fatal in consequence of the quan- 
tity of blood discharged. In my opinion, there are 
good reasons for believing that such hemorrhages are 
efforts of nature to relieve a sthenic condition of the 
system ; thus pointing out to us the error we have 
committed in withholding the use of the lancet in 
the earlier stages of the disease. This view is sus- 
tained by the fact that such hemorrhages rarely ever 
follow a course of active depletion by general blood- 
letting, in such early stages. And they may indicate 
to us, also, that bloodletting may be successfully em- 
ployed in the more advanced stages of the disease, 
when physicians rarely think of resorting to it, pro- 
vided we are wise enough to imitate nature in the 
gradual abstraction of blood. I have on several oc- 
casions ventured to make this experiment, and drawn 
blood from the arm in small quantities, frequently re 
peated, when it was evident that hemorrhage was im- 






Lectures on Fever. 139 

pending, and with good results. Several bleedings in 
such cases may be obtained from the same orifice, 
which keeps open much longer than in the more ac- 
tive stage of the fever, and it is sometimes practica- 
ble to draw the blood very slowly, in a stillicidious 
manner, in imitation of the operations of nature. 
Should these operations be anticipated in time, and 
without causing undue prostration, the threatened 
hemorrhage may be prevented. Two objects are 
gained by this practice, namely, the relief of vascu- 
lar turgescence at an earlier period than by the spon- 
taneous hemorrhage, and the control we secure over 
the discharge of blood ; but it must be borne in mind 
that this practice must be regulated by great care and 
delicacy, lest the patient may sink under the opera- 
tion. 

It is often difficult to regulate the discharge of 
blood in these hemorrhages, to prevent exhaustion 
and fatal effects. This is generally attempted by the 
use of astringents of various kinds, both internally 
and topically, but I have generally found turpentine 
to be the most valuable internal remedy. "When the 
bleeding occurs from parts of the body which are ac- 
cessible to the application of topical remedies, sugar 
of lead and tannin, one or both, are generally relied 
upon ; but the most efficient styptic I have used is, a 
combination of tannic acid and elixir of vitriol. This 
is a remedy of no mean power for internal adminis- 
tration also. 



x LECTURE IX. 

YELLOW FEVER. 

Haying now given you some account of fever in 
general, and of various forms or types of periodic 
fever, it remains to make some remarks upon certain 
peculiar forms of febrile disease, which have been 
considered distinctive, in both causation and pathol- 
ogy. One of these forms is yellow fever — the most 
extended, long-continued, and fatal of all the epi- 
demic diseases which have afflicted mankind; thus 
affording abundant opportunities for investigating its 
character. But, notwithstanding all this, there are 
few diseases about which there exists a greater variety 
of opinions, and a greater discrepancy of views. It 
cannot yet be considered a settled matter, whether it 
is a disease sui generis, or merely a variety of peri- 
odic fever. The preponderance of opinion has some- 
times seemed to be on one side of the question, and 
sometimes on the other ; but at the present time, 
probably, the affirmative has the larger number of 
advocates ; although it is known that this cannot be 
distinguished from other forms of fever in its earlier 
stages. 



Lectures on Fever. 141 

The disputes on this subject are virtually the same 
that have prevailed in regard to fevers in general ; 
and it would be both curious and instructive, could 
we spare the time, to go into an examination, in this 
connection, of these strange discrepancies in medical 
opinion. I shall take occasion to refer to only a few 
of them. Copland says, fever is but one disease ; 
Payne, that the cause of fever, as of inflammation, is 
essentially the same. Southwood Smith says, there 
is but one continued fever; but Jenner recognizes 
four. We find in fever, says Holland, a bond by 
which to associate numerous forms of disease ; a knot 
so intricate that it cannot be unravelled. Bartlett 
knows of only the following distinct forms of fever, 
namely, typhoid, typhus, periodical, congestive, yel- 
low. Fenner reports sixteen nominal varieties, all 
which, however, he considers only varieties of one 
general disease. Bryson says, the fevers of Africa are 
only divisible into two kinds, remittent and intermit- 
tent. Other names employed he considers without 
distinct meaning; as jungle, mixed, and coast fever. 
The adjectives ardent, yellow, congestive, and inflam- 
matory, he applies to one and the same disease, and 
says, the synochal is converted into the remittent, and 
terminates in the intermittent ; the mild ephemeral 
is suddenly followed by high vascular excitement, and 
finally becomes typhoid. Landor believes, there is 
but one fever poison, arising from some general, but 



142 Lectures on Fever. 

as yet unknown, cause. A prominent writer in an 
English journal thinks, there is but one virus, produc- 
ing all the forms and grades of fever, the graver 
forms being contagious. Dickson strangely contends, 
that each and every type of fever is the result of a 
distinct and definite cause ; and that several of these 
causes may coexist and produce a blending of types ; 
and that one type may be substituted for another, etc. 
Applying these principles to the different types of 
periodic fever, to inflammatory, typhoid, typhus, the 
mild, malignant, simple, congestive, and to all other 
forms of fever, he makes a fanciful complication, 
which, like the old hypotheses, to which I have re- 
ferred in previous lectures, cannot pretend to have 
any foundation in established facts. These discrepan- 
cies and anomalies, not to mention others, serve to 
show how unsettled is medical opinion, and to justify 
me in giving my own. 

From all the facts in the case, regardless of spe- 
cious theories, I think we are justified in the conclu- 
sion, that fever is one disease, affecting always all 
parts of the system ; but of two varieties, idiopathic 
and symptomatic. The former arises from the influ- 
ence of some external cause, the origin and nature of 
which is not know T n, and is wholly independent, in 
its inception, of local irritation and inflammation. 
The latter is produced by the disturbing influence of 
some local disease, either primary or secondary. The 



Lectures on Fever. 143 

idiopathic variety may be mild and ephemeral, or 
grave and persistent ; but the certain effect of its con- 
tinuance is, the production of local disease according 
to the predisposition of the patient, or in obedience 
to some epidemic influence. Either variety may be- 
come continued, as far as fever ever is continued, 
from the influence of local irritation. Symptomatic 
fever may become periodic, under the influence of the 
cause of periodicity ; and it may be secondary to 
idiopathic fever, from the retroactive effect of the 
local lesions which it has produced. Either form may 
be called hepatic, gastric, enteric, pneumonic, cerebral, 
etc., according to the seat of its prominent local 
lesion, whether such lesion be primary or secondary. 
In yellow fever, according to all writers on the sub- 
ject, the prominent local affection is inflammation of 
the stomach ; but it is not believed that this is the 
primary disease, existing anterior to, and giving rise 
to the fever. So far from this being the case, it is 
well known that the fever always exists for one or 
more days, before the appearance of any of the symp- 
toms peculiar to gastric irritation or inflammation. 
Until signs of the existence of this gastric lesion make 
their appearance, yellow fever differs so little from 
other forms of fever as to baffle all attempts at diag- 
nosis. Hence the disagreements common among 
physicians, as to the true character of all epidemics 
of this disease, in their early stages. The closest ob- 



144 Lectures on Fever. 

servers fail to discover any difference between this 
and other forms of fever, for the simple reason that 
there is no difference. But after some cases have run 
their course, to the development of the gastric symp- 
toms, then all agree to call the disease yellow fever, 
from the beginning ; and this has been the history of 
all the epidemics of this disease in this country. Some 
peculiarities may indeed exist from the commence- 
ment, but there is no criterion by which the charac- 
ter of the disease can certainly be determined, until 
the gastric disorder is established. Nor is this fea- 
ture peculiar to yellow fever, for the same is true of 
the enteric, hepatic, pneumonic, and other forms of 
fever, and also of the exanthematous fevers. Unless 
we have a clue to their true character, from the known 
prevalence of epidemic or contagious influences, we 
can only become fully assured of it, by the develop- 
ment of their peculiar local lesions, whether of some 
internal organ or tissue, or of the skin. 

I am of the opinion, therefore, that yellow fever dif- 
fers only from the other forms of periodic fever in 
this : that for some unknown reason it has its prominent 
and characteristic local lesion in the stomach. This 
gastric lesion appears first in the form of irritation, 
and this culminates more or less rapidly, according to 
the violence of the disease, into inflammation, simu- 
lating gastritis from any other cause ; but generally 
it is more severe in its character, and more rapid in 






Lectures on Fever. 145 

its course. All writers on the subject acknowledge 
this gastric character of the disease ; and Copland is 
so impressed with its distinctive nature that he pro- 
poses to discard the name yellow fever, which has as 
little pertinency in this case as jungle, swamp, and 
bilious fever have in others, and to substitute the 
more appropriate and significant designation, hsema- 
gastric pestilence. 

This disease, beyond all question, exhibits, in its 
early stage, all the characteristics of periodic fever ; 
and, so far as is known, or can be proved, it is attrib- 
utable to the same cause. Why in this case the princi- 
pal local lesion should be found in the stomach, rather 
than in some other organ, can no more be explained, 
in the present state of our knowledge, than can the 
existence of certain local lesions in other cases, in 
other organs of the body. Nothing can be more cer- 
tain, however, than that the position of the principal 
local disease in all fevers, whether existing as cause 
or effect, impresses its character upon the general dis- 
ease, and very properly furnishes the epithet which 
distinguishes it from other forms of fever. Accord- 
. ingly, the proper designation of this disease is, gastric 
fever. 

It prevails mostly in hot climates, or in the hot 

season of temperate climates ; and it is said not to 

become epidemic without at least two previous months 

of hot weather, during which time the average tem- 

1 



146 Lectures on Fever. 

perature lias been as high, as seventy-nine or eighty 
degrees Fahrenheit. Commonly it becomes epidemic 
in this country in August or September, though 
sometimes garlier and later in the season ; and in 
temperate latitudes it subsides upon the occurrence of 
freezing weather. In tropical countries, its course is 
run in three or four months ; after which the epide- 
mic gradually subsides ; but in both instances sporadic 
cases continue to occur for several weeks afterward. 
But exceptions to these rules are frequently occurring, 
and it may well be doubted whether any climate or 
season is entirely exempt from this disease ; although 
it is not likely to become epidemic in cold climates 
and seasons anywhere. Like other diseases, and 
other forms of fever, it has a preference for certain 
localities, and without our being able to perceive the 
reason why. 

In the Old "World, and especially in Africa, yellow 
fever has been known for ages, but it is not more 
than a century, probably, since it first became epide- 
mic in America. For many years it was confined, 
principally, to the "West-India Islands. Until quite 
lately it was unknown, as an epidemic, in Rio Janei- 
ro ; and to this day it has not appeared at Canton, 
Calcutta, Alexandria, Smyrna, or Constantinople ; all 
of them cities which would appear just as likely to 
invite its incursion as New-Orleans, Havana, and 
Philadelphia. If any theory of its causation were 







Lectures on Fever. 147 

true, -which has ever been promulgated, it would be 
difficult to determine why the above-named, and many 
other cities, should have been exempt. In all the 
labored essays upon the etiology of this disease, no 
good reason has ever been suggested why it should 
visit certain cities in warm latitudes every year, to 
the exclusion of others similarly situated ; or why it 
should become epidemic in one year more than in any 
other. Indeed, yellow fever is not confined to cities, 
although it is in them that the worst epidemics gen- 
erally prevail. Some of the most violent cases I have 
seen originated in country localities ; and it has been 
proved by Dr. La Roche, of Philadelphia, that it has 
occurred on board of ships which had been for months 
at sea, without entering port. Xo place appears to be 
exempt from its visitations, excepting only closely 
confined prisons. 2so instance, I believe, is related of 
the origin of yellow fever in such places. 

No good reason has been given why yellow fever 
should be attributed to any other cause than that 
which produces other forms of fever ; but medical 
literature abounds with arguments, surmises, and 
conjectures on this subject, in the examination of 
which you can indulge your leisure hours. If you 
confine your attention to actual facts, however, I think 
you will be forced to the conclusion, that we are not 
better informed in regard to this matter than we are 
in relation to the causes of other forms of fever, and 



148 Lectures on Fever. 

of many other diseases. ~No cause has ever been 
suggested by authors, which may not exist without 
producing the disease ; and nothing is more certain 
than that the fever may exist in the absence of every 
cause which has been named as capable of producing 
it. We can no more determine what causes this, or 
any other form of fever, than we can tell by what 
agency particular organs of the body become diseased 
as effects of fever. These things are still among the 
arcana of our profession, and we cannot hope to ex- 
tricate them from obscurity by idle speculations. 

As in other forms of fever, the attacks of this dis- 
ease are slow and insidious. When prevailing as an 
epidemic, the first indications of its approach are gen- 
erally felt in the night. They are the usual signs of 
incipient fever, but often, for several successive nights 
and days, the symptoms are so slight as scarcely to 
attract attention. The subject is aware of the exist- 
ence of some abnormal movements and sensations ; 
but as these soon pass away, and do not interfere with 
his active duties, they are soon forgotten. Indeed, 
the transient indisposition is not unfrequently follow- 
ed by a kind of excitement which is not of an un- 
pleasant character, and which sometimes gives rise to 
the declaration, that the sufferer is in the enjoyment 
of the most perfect health. This slight indisposition 
is not unfrequently followed by an exuberance of ani- 
mal spirits, and the patient laughs at the idea of dan- 



Lectures on Fever. 149 

ger. But lie is certain to be soon undeceived. The 
cumulative power of the exciting cause deepens its 
impression upon the animal economy, at every recur- 
rence of the daily paroxysm, until the patient is pros- 
trated, and calls loudly for hel$. This is apt to be /- 
considered the actual period of attack, and hence the 
idea that the disease comes on suddenly and power- 
fully, than which there is no greater mistake in con- 
nection with this formidable disease. It is not thus 
suddenly, indeed, that any form of fever attacks the 
human body. The cause acts upon the system grad- 
ually, so as in some cases to be resisted by the powers 
of nature. Time is always required, longer or short- 
er in different persons, for the cumulative influence to 
produce decided effects. 

The symptoms of yellow fever, in its early stages, 
do not differ from those of other forms of fever to a 
sufficient extent to enable us to diagnosticate the dis- 
ease from these alone. They are the common symp- 
toms of periodic fever, and generally of so mild a 
character as to induce the physician to venture upon 
a favorable prognosis. The inexperienced are fre- 
quently led astray by this, even in severe epidemics, 
and hastily commit themselves to opinions which are 
soon falsified by results. The chill is like any other, 
and if the reaction differs from that in other fevers, it 
is generally on the side of moderation. The pain in 
the head, back, and limbs, is perhaps more violent 



150 Lectures on Fever. 

than we could reasonably have expected in such mod- 
erate febrile excitement, and the conjunctivae more 
injected. The tongue is not often thickly coated, and 
the complainings of the patient are sometimes such 
only as attend upon the beginning of a common cold. 
The paroxysms becoming more severe, are soon 
followed by signs of gastric disorder, and then 
we have, from such time forward, to contend with 
all the appalling conditions attending upon ma- 
lignant gastritis. Tew physicians are familiar with 
this local disease in its idiopathic form, as it is one 
of very rare occurrence. Several eminent European 
physicians have declared that they have met with only 
a few cases of gastritis in the course of a long-contin- 
ued private and hospital practice. I have myself seen 
only four cases, which were caused by habitual drunk- 
enness, pregnancy, and poisoning, and each of these 
simulated yellow fever very closely, three of them 
ending in black vomit. They were, indeed, cases of 
gastric fever, of the symptomatic kind.* 

* Since this lecture was written, I have treated a somewhat remark- 
able case of gastritis, from the influence of pregnancy. Mrs. B., of 
Memphis, Tennessee, in the sixth month of her fourth pregnancy, was 
seized with nausea and vomiting, which continued, with constantly in- 
creasing violence, for fourteen days. On the eleventh day the disease 
had assumed all the symptoms and external appearances of yellow fe- 
ver, insomuch that her attendants and friends, who were familiar with 
the disease, became much alarmed on account of it. During the last 
three days, the skin and eyes became yellow, the fluid ejected from the 






Lectures on Fever. 151 

In most cases of yellow fever there is a decided 
abatement of pain in the head, back, and limbs, and 
it is then that the gastric symptoms develop them- 
selves with distinctness. These are, nausea and vom- 
iting, thirst, soreness and oppression at the epigastri- 
um, a sensation of heat in the stomach and bowels, 
constipation, or else watery stools, great restlessness, 
anxiety, delirium, and sometimes coma. The eyes 
become dull, heavy, and bloodshot, the skin and 
tongue cool and yellowish ; the secretion of urine is 
lessened or entirely suspended, the pulse becomes 
slow and feeble, black vomit and low muttering de- 
lirium set in together, and a lingering stertorous in- 
sensibility leads gradually to death. 

This is a brief description of a fatal case of yellow 
fever, and it is also a description of fatal gastritis aris- 
ing from any other cause ; a disease^ which is by far 
the most insidious, deceptive, and dangerous of all the 
diseases which physicians in this country are called 
on to treat. No other disease is so brief in its course, 
so distressing and fatal, without affording more decid- 

stomach assumed a glairy and acrid character, containing floating floc- 
culi as in the early stages of black vomit in yellow fever. These 
were constantly increasing until the last day, when she threw up vast 
quantities of black vomit, with similar discharges from the bowels. 
The usual delirium came on, and she died almost in the act of giving 
birth to the foetus. This case occurred in the month of June, when the 
city was healthy, without any sign of yellow fever, and so it continued 
during all the summer and autumn. 



152 Lectures on Fever. 

ed evidences of its existence and dangerous character 
in its early stages. A patient with gastritis, whether 
caused by drunkenness, local irritants, pregnancy, or 
fever, will often be far gone toward a fatal termina- 
tion before it can be known, from any existing symp- 
toms, that life is in danger. It is a mistake, there- 
fore, to suppose, that it is in yellow fever only we 
have to contend with this difficulty, although it be 
true that a merciful Providence has rendered gastritis 
a rare disease from other causes. To me it is quite 
evident, as the result of my own experience, that the 
peculiarities of yellow fever are the peculiarities of 
severe cases of gastritis, with the superadded disad- 
vantages arising from fever primarily existing. 

There has been much difference of opinion, as to 
the existence of periodicity in yellow fever, nearly all 
modern writers on the subject contending that it is a 
fever of a single paroxysm, continuing three days, or 
longer. I consider this to be a grave and extraordi- 
nary mistake. I have carefully observed the febrile 
movement in thousands of cases of this disease, and 
therefore give my opinion upon the subject with con- 
fidence. The error, I apprehend, has arisen from the 
fact, that the exacerbation and the remission are, in 
general, less distinctly marked than in some other 
forms of fever, and especially in violent cases ; and 
from the more important fact, that the daily remission 
in this, as in other grave forms of fever, nearly always 






Lectures on Fever. 153 

takes place very early in the morning, when it is least 
likely to be observed. From all my observation and 
experience, indeed, I conclude that the human system 
cannot and never does sustain a continued febrile ac- 
tion without remission, for more than a single day. 
The periodic movement, in a large class of diseases, 
would seem to indicate this as a law of the animal 
economy. But however this may be, it is very cer- 
tain to my mind, that in all cases of yellow fever 
there is, in fact, a daily remission. This occurs about 
the dawn of day, which, on this account, is the im- 
portant period for the application of remedies ; and a 
physician who fails to notice and take advantage of it, 
is not likely to be very successful in treating the dis- 
ease. 

A remarkable feature in this disease is, the sudden 
and entire suspension of febrile excitement, in some 
of the more violent cases, just before a fatal termina- 
tion. The patient and his attendants are apt to be 
wholly deceived by this calm remission, which gener- 
ally appears, like other remissions, early in the morn- 
ing, and is a state of utter hopelessness. But this is 
peculiar to malignant gastritis in every form. A con- 
firmed drunkard laboring under gastritis, in this city, 
rose early one morning from a bed, to which he had 
been helplessly confined for more than a week, de- 
clared himself quite well, walked for half an hour or 
more up and down the room, congratulating himself 



154 Lectures on Fever. 

upon his recovery, then threw himself upon a pallet 
on the floor, and immediately expired. The extraor- 
dinary muscular strength exhibited by some, just be- 
fore death, is another strange anomaly belonging to 
gastritis. Both these peculiarities are apt to exist in 
connection with black vomit, but this is not always 
present with them. 

Yellow fever is a disease of sthenic character, bear- 
ing, and often requiring, active depletion and contra- 
stimulation. The symptoms fully justify this conclu- 
sion, and I have demonstrated its truth by active de- 
pletion in hundreds of cases. But in severe and fatal 
diseases, the stage of excitement above the standard 
of health is sometimes quickly followed by a stage of 
collapse below that standard ; and it is evident, that 
the treatment proper and necessary in the former, 
would be injurious and perhaps fatal in the latter 
stage. When I recommend free and copious blood- 
letting as a remedy, therefore, you are not to 
consider it as advised for all stages and under 
all conditions. It is the main business of physicians 
to discriminate in such matters, and it is for want of 
it that the remedy has been brought into partial dis- 
repute, by repeated failures. But it is all the more 
necessary in yellow fever, because the condition of 
the stomach precludes the use of tartar emetic and 
other sedatives, on account of their nauseating and ir- 
ritating effects upon that viscus. General and topical 









Lectures on Fever. 155 

bloodletting must therefore be relied on, together 
with cold bathing and cold eneniata, to relieve sthenic 
action. 

It is not less evident to my mind, that yellow fever 
is a periodic disease, but the remedies for this must 
also be well timed. I have told you, in a former lec- 
ture, that the common effect of quinia is, when given 
in the exacerbation, to enhance the febrile force ; al- 
though in cases of moderate violence, large doses of 
quinia may, even in this stage, cause sedation. In so 
grave a disease as this, it would be imprudent to try 
such experiment. The proper time for the remedy in 
this, as in other forms of periodic fever, is in the pe- 
riod of remission ; and as this is short in all violent 
cases, you may increase the chances of success by be- 
ginning its exhibition just as soon as there are evi- 
dences of an abatement of the paroxysm. And it 
must always be borne in mind, that success depends 
much upon the early application of remedies. Every 
successive paroxysm lessens, in a rapid ratio, the 
chances of cure. 

The use of purgatives, to the extent required to 
prevent intestinal accumulations, is very important. 
Even after all the ingesta have been evacuated, the 
bowels become, in short intervals of time, overbur- 
dened with excreta, which must be promptly dis- 
charged, or distressing consequences will follow. 
And these remedies, namely, bloodletting, refriger- 



156 Lectures on Fever. 

ants, antiperiodics and cathartics, must be our princi- 
pal reliance. If we know when and how to use them, 
and have the proper opportunity, many cures may be 
effected ; and it is of little consequence about the 
thousand other remedies recommended. In cases of 
early collapse, great benefit is often derived from 
warm clothing and hot beverages. 

It is proper to remark here, that in what I have 
said I have had in view only the more violent grades 
of the disease, such as always prove fatal unless re- 
lieved by treatment. But you are not to infer that I 
consider the disease to be always of a violent and dan- 
gerous character. On the contrary, there are, in all 
epidemics of yellow fever, many cases of a mild and 
tractable grade ; or, to be more exact, all cases are 
mild in their inception, and it is only a portion that 
become severe. Native-born citizens of hot climates, 
and persons who have once suffered a severe attack of 
the disease, are generally relieved by mild treatment, 
and not unfrequently recover without the use of rem- 
edies. And it is not improbable that the time will 
come, when a large proportion of those attacked will 
be cured by early and judicious treatment. It may 
be hoped, indeed, that by the use of preventives, in 
the form, perhaps, of antiperiodic medicines, this and 
other forms of periodic fever may be prevented. 

The jpost-mortem appearances in this, as in many 
other diseases, are only a poor guide in diagnosis. 






Lectures on Fever. 157 

The stomach always shows signs of more or less in- 
flammation or congestion, but not at all commensu- 
rate in degree with the violence of symptoms. There 
are also, in general, evidences of diseased action in 
the brain, liver, bowels, kidneys, etc., but they are 
rarely ever such as those who have witnessed the 
progress of the disease would expect to find. I have 
known the body of a man dead of yellow fever to 
be dissected before a medical class, without creating 
any suspicion of the cause of death. Yet there are, 
in the outward appearances, strong indications of the 
character of the disease, and which leave little doubt 
upon the mind of the experienced observer. When 
the patient has had black vomit, the proof is more 
positive. This is found in large quantities in the 
stomach and duodenum, and sometimes throughout 
the intestinal canal. 

The black vomit is ascertained to be gastric and 
enteric hemorrhage, and it is one of the effects of the 
disease about which there has been much difference 
of opinion. It is not constant, and not more an es- 
sential symptom of yellow fever than occasional hem- 
orrhage is of other forms of fever. "When accom- 
panied by aberration of mind, as it generally is in 
yellow fever, black vomit may be considered a pretty 
certain indication that the gastric inflammation has 
passed into the gangrenous state, rendering the case 
hopeless. Hemorrhage sometimes occurs in the 



158 Lectures on Fever. 

stomach and bowels, in fever, without gastric inflam- 
mation, and not being accompanied by aberration of 
mind, and the other fatal symptoms of yellow fever, 
it is not only not fatal, bnt a critical discharge, like 
hemorrhage from other parts of the body. The dif- 
ference seems to be this : that of gastritis occurs in the 
gangrenous, and that of other forms of fever, in the 
congestive or inflammatory stage. One is a sign of 
approaching dissolution ; the other, an effort of nature 
to relieve the mucous membrane of its engorgements. 
One is a fatal, the other, a critical discharge. This 
is an important distinction. 







LECTUKE X. 



PNEUMONIC FETEE, 



Pneumonic fever is another variety of febrile dis- 
ease which requires special remark, because not only 
of the discrepancies in opinion regarding it, but on 
account also of the general prevalence of the disease 
in all the Southern States during the winter season. 
The common doctrine has been, that pneumonia is 
primarily a local disease, an idiopathic inflammation 
of the lungs, and that the fever which attends upon 
it is a secondary affection, or symptomatic fever, 
caused by the irritation proceeding from the local af- 
fection. And doubtless it is true of the lungs, as of 
other organs of the body, that they are liable to idio- 
pathic inflammation, causing symptomatic fever. 
Perhaps in a large majority of cases in non-malarious 
regions, the disease is a local one in its inception and 
early stages, and sometimes this may be its character 
also in malarious districts. But it is undoubtedly 
true, that in these latter, with which we have to do in 
the practice of our profession, the fever is almost uni- 
formly the primary affection, and the local lesion 



160 Lectures on Fever, 

which gives the disease its name is secondary, and the 
peculiar local lesion of the fever. 

These views, which I have for many years held, 
and upon which I have constantly acted in the treat- 
ment of this disease, have, as some of you may chance 
to know, been called in question, and most ably con- 
troverted. A short and unpretending essay of mine 
upon this subject, first published in the New-Orleans 
Medical Journal^ and afterward issued in a pamphlet 
form, had a principal agency in the production of a 
large octavo volume, by Doctor La Roche, of Phila- 
delphia, one of the most elaborate and able medical 
writers America has produced. The exclusively local 
character of the disease is in that work most ably ad- 
vocated, and at such length, as to quite exhaust the 
argument on that side of the question ; but with the 
full acknowledgment that the local and general dis- 
ease, the inflammation of the lungs, and the fever, are 
often most intimately blended ; but not in such man- 
ner as to make it proper to direct our means of cure 
primarily to the relief of the general disease, rather 
than the local. The argument of Dr. La Roche on 
the origin and influence of malaria, in the work to 
which I refer, is very ample, eloquent, and comprehen- 
sive, leaving little to be said on that side of the ques- 
tion by others. But he has not proved, nor can it be 
proved, that malaria, or any other reputed cause of 
fever, does not give rise to a febrile affection, that 






Lectures on Fever. 161 

may have its most prominent local lesion in the lungs 
as well as in other organs of the body ; the former 
being the primary and the latter the secondary affec- 
tion. 

In my brief essay, before referred to — an essay of 
only seven pages — which was read before the Mem- 
phis Medical Society in 1851, I made the following 
observations, which were taken as a sort of text for 
the ponderous volume of my distinguished friend: 
u According to my observations, the pneumonias 
which prevail in this country . . . are really and 
substantially nothing more than a peculiar form of 
remittent or intermittent fever. . . . This pro- 
tean character of our fevers arises in part from the 
season of the year and the particular localities in 
which they occur ; but mainly from the organs of the 
body which become involved in the diseased action, 
the predominance of inflammation, or congestion, and 
the character of periodicity. In the spring, we are 
apt to find these diseases assuming the names which 
have reference more particularly to this periodicity 
and general pathology. As summer comes on, the 
greater complication of the hepatic organs changes 
the name, or adds an epithet to designate a promi- 
nent symptom. In autumn, the chylopoietic viscera 
become more strikingly involved in the diseased ac- 
tion ; and this again is indicated by an ever-changing 
nomenclature. But when winter approaches, and the 



162 Lectures on Fever. 

subjects are exposed to sudden transitions of tempera- 
ture, the thoracic viscera are called upon to bear the 
burden of local disease, and then it is that the names 
pleurisy, pneumonia, pneumonia t yphoides, pneumo- 
nia biliosa, pleuro-pneumonia, bilious pleurisy, lung 
fever, etc., become familiar sounds." 

Now, to show you that such views are not singular, 
you may see, on perusing this remarkable work of 
Dr. La Roche, that they have been sustained by 
many distinguished medical writers ; such, for in- 
stance, as Lancisi, the great originator of the doctrine 
of miasm ; Sydenham, the projector of the most con- 
venient of all etiological theories, the " epidemic con- 
stitution of the atmosphere ;" Cleghorn, the philoso- 
phical observer of the diseases of Minorca, so similar 
to our own ; Rush, the father of American medicine, 
and the true expounder of the fevers of Philadelphia ; 
Copland, Good, Broussais, Watson, Chalmers of 
South-Carolina, and Condie, Wood, Bell, and others, 
of Philadelphia. Many other distinguished names 
might be added, but these are enough for my present 
purpose, which is to show you, that the doctrines 
which I am advocating are not peculiar to myself. I 
only claim the credit, if there be any credit in it, of 
discovering the applicability of these doctrines to the 
disease as it prevails in the South, and of calling to it 
the attention of physicians, and especially of physi- 
cians from the North practising in the South. 



Lectures on Fever. 163 

As in other forms of periodic fever, this disease 
comes on with a chill, passing through the different 
stages of the paroxysm ; but in most cases, the early 
paroxysms are mild and transitory. These become 
more and more severe at every succeeding recurrence, 
and no signs of the pneumonic affection appear for 
several days. Condie says : " In many instances, it 
is only after the fever has continued several days that 
pain in the chest is complained of." "Wood remarks, 
that "in those cases in which the fever is the primary 
affection, the chill and febrile symptoms generally 
precede those proper to the pneumonia for one, two, 
or three days, and sometimes a longer period." Bell, 
after speaking of the febrile symptoms, goes on to 
say : " To-day the patient complains of gastric symp- 
toms ; to-morrow, of a tendency to cerebral conges- 
tion ; subsequently, of rheumatic pains ; until finally 
the pneumonia discloses itself." Do these look like 
proper descriptions of idiopathic pneumonitis ? They 
describe the early stages of pneumonic fever very 
well, but the descriptions are equally well suited to 
the early stages of gastric, enteric, and hepatic fever. 
When periodic fever first assails the human constitu- 
tion, no one can certainly determine what will be its 
ultimate character, and what particular organ of the 
body is destined to suffer most, except from a know- 
ledge of the epidemic influences prevailing. Indeed, 
nothing is more common, than for other organs than 



164- Lectures on Fever. 

the one which is to be the final seat of the disease, to 
be more seriously threatened, until several febrile par- 
oxysms are passed. 

The local lesion in this variety of fever is generally 
obscure in its early manifestations, insomuch that 
physicians are sometimes deceived as to its existence, 
until it has become of a very serious character. At 
those seasons when this complication may be expected, 
or at times when the disease is prevalent, we have 
reason to be on the alert for the discovery of pneu- 
monic symptoms. These are, pain in the chest, quick- 
ened respiration, florid countenance, etc. ; but the 
most certain means, perhaps, for the discovery of in- 
cipient pneumonitis is by auscultation. There is a 
sound in the act of respiration called crepitant rale, 
easily detected by those who are experienced in such 
examinations, and which is said to indicate the exist- 
ence of the pneumonic inflammation, even before it 
could be suspected from other symptoms. But in 
most cases it is not pneumonitis alone that constitutes 
the local lesion. The pleura is quite as likely to be 
implicated, and also the bronchial tubes. Bronchitis, 
I believe, nearly always exists, from the intimate con- 
nection between the bronchial tubes and the paren- 
chymatous structure of the lungs. As the disease 
progresses, the liver also becomes implicated, and 
hence the adjective hepatic, or bilious, is so often add- 
ed. We have, therefore, a combination of pneumo- 



Lectures on Fecer. 165 

nia, bronchitis, pleurisy, and hepatitis, as I 

but the pneumonitis is the most prominent, and very 

justly gives character and name to the disease. 

If the febrile symptoms are early met by the appro- 
priate treatment, the local disease cannot become 
troublesome, and it may not be so far developed as 

d to be noticed. But several iu 
ysms istantly increasing intern Lthoui reme- 

dial measures, must inevitably create such a de_ 
of local disturbance, as to require the most skilful 
trnent to insure relief. You have then imposed 
upon you the task not only of curing the : liieh 

in the earlier stage would have been an easy matter, 
but of managing local irritation and inflammation of 
the most delicate nature, and which are constantly on 
the increase in their intensity. The fever also be- 
comes more persistent, from the reciprocal influences 
of the local disease, as in cases oi symptomatic fever. 
It will be evident at every step of progress in the 
treatment, that the local affections cannot be relieved 
while the daily paroxysms of lever continue, nor 
the fever be wholly subdued while the system is la- 
boring under the influence of a well-established local 
inflammation. Your treatment must therefore be 
signed for the relief of both : it must be constitutional 
and topical, antiperiodic and antiphlogistic. 

In the preliminary stage, and before the local le- 
sions are fully established, the disease may be un- 



166 Lectures on Fever. 

doubtedly cured by the usual antiperiodic treatment 
alone ; and in that case we are not likely to hear any 
thing said of pneumonia. As in gastric or yellow 
fever, the constitutional disease subsides before its 
peculiar local lesion appears, and the case passes as a 
common or ephemeral fever. But after the thoracic 
lesions are produced, the disease assumes a character 
somewhat more serious, and the treatment becomes 
proportionally complicated. You have not only a 
local affection of a serious nature to contend with, 
but the fever has become intensified by repeated re- 
turns of the paroxysm, at the same time that it is 
rendered more unmanageable by the local irritation. 

Bloodletting, when properly timed, relieves the 
congestions and equalizes the circulation, affording 
great advantages in the subsequent treatment. As 
in other forms of periodic fever, however, it is princi- 
pally valuable in the early stages of the disease, and 
the extent to which it may be carried depends upon 
the violence of the attack, and the prevailing severity 
of the disease in other cases. When the local lesions 
have become developed, it is still a useful remedy, 
and sometimes essential ; but in many cases the pneu- 
monic affection is more of an irritative than inflam- 
matory character, and bloodletting is not required, as 
in cases of gastric and enteric inflammation ; and in 
the more advanced stages it must be used with much 
caution, as there is danger that the vital powers may 






Lectures on Fever, 16 7 

be reduced below the standard of health, when the 
loss of blood would be dangerous and perhaps fatal. 
In some epidemics of this disease, there is a strong 
tendency to a reduction of the vital powers, and such 
cases are called typhoid In negro subjects, the pros- 
tration is sometimes very sudden, and death ensues on 
the third or fifth day. In such cases, bloodletting is 
a dangerous remedy, and it cannot be used after the 
inceptive stage, if, indeed, at all. In many cases of 
pneumonic fever, topical bloodletting is the safer and 
more efficient remedy ; and sometimes dry cupping is 
to be preferred. 

Tartar emetic has justly attained great celebrity as 
a remedy in this form of fever. Its importance, in- 
need, can scarcely be over-estimated. It should be 
given in frequently-repeated doses, especially during 
the exacerbation of fever, and in such quantity as the 
stomach can tolerate. It is only by experiment that 
we can ascertain what amount any patient will be 
able to take ; therefore it is best to begin with small 
doses, say as small as one sixteenth of a grain, and to 
increase the quantity from dose to dose, until nausea 
is produced, or even vomiting. Then, after suspend- 
ing it for two or three hours, it will be found that 
the patient will be able to bear larger doses than be- 
fore. I prefer, in most cases, to repeat the tartar 
emetic every hour, that its sedative effect may be 
steadily maintained. Tartar emetic in crystals should 



168 Lectures on Fever. 

always be preferred, to avoid the adulterated article 
often sold in the shops. The good effects of this rem- 
edy are greatly increased by the concurrent use of the 
nitrate of potash, which, if well diluted, may be given 
in doses of ten to twenty, and even forty grains ; but 
the two medicines should not be combined, nor should 
the nitrate be given as often as the other. The free 
use of diluent drinks is an essential concomitant of 
this treatment, and especially if large doses of nitrate 
of potash are given. Without these, the stomach will 
suffer from too great irritation. 

Opium, which is so mischievous in other forms of 
fever, except in their early and forming stages, and 
which is so fatal a poison in gastric fever, may in 
general be used in moderate quantity during the 
whole course of pneumonic fever. The disordered 
innervation with which fevers begin their course, ap- 
pears to be perpetuated in this variety, and the prin- 
cipal local lesion being in the thoracic viscera, there 
is less danger of interference with important secretions 
by the use of opiates. When expectorants are em- 
ployed, there is another reason why opium may be 
useful. This class of remedies have a diuretic as well 
as expectorant effect, and when they operate actively 
on the kidneys, we have little to expect from their ex- 
pectorant effect; and this diuresis is prevented, in 
great measure, by opium. Still, it is no uncommon 
thing, I apprehend, to witness the use of opium in 



Lectures on Fever. 169 

this form of fever to an injurious extent. In the 
progress of the disease, especially when protracted, 
the liver and other viscera of the abdomen become 
seriously implicated, and just in proportion as they 
do so, opium becomes injurious by reason of its effect 
in retarding secretion in those organs. 

Chloroform is a valuable substitute for opium in 
this and other forms of periodic fever, and over which 
it possesses many advantages. It is more powerful to 
relieve congestion, equalizing the circulation of the 
blood more promptly, and exercising little or no in- 
fluence to the injury of glandular action. If given 
in the chill, the patient is sometimes so completely 
relieved that very little morbid or febrile reaction 
follows ; and frequently the congestions which cause 
such embarrassment to the respiratory function yield 
to the influence of chloroform more readily than to 
any other remedy, not excepting bloodletting. This 
medicine has not yet come into extensive use in fe- 
brile affections, but such is its power over the nervous 
system that I venture to predict for it as prominent a 
place in our catalogue of internal remedies as it now 
occupies in our list of anaesthetics. In severe cases, 
it may be given in doses of a fluidrachm.* 

Calomel is the safest and most efficient cathartic in 
this disease ; but on account of the use of opium it 

* These remarks have reference, exclusively, to the introduction of 
chloroform into the stomach, and not to inhalation. 



170 Lectures on Fever. 

is sometimes necessary to assist its operation with 
castor oil. It is important that cathartics should be 
administered in such manner as to secure the dis- 
charge of thick feculent stools. Whenever a hydro- 
gogue effect is produced, there will be an increase of 
pneumonic symptoms ; and in the advanced stage of 
dangerous cases, a few copious watery stools are very 
likely to prove fatal. The proper management of the 
bowels, therefore, is an important consideration in this 
disease; and I have often found aloetic purgatives 
useful. Their action upon the rectum is beneficial in 
the way of counter-irritation ; and there may be rea- 
son to believe that counter-irritation at this point ex- 
erts a special influence over the lungs, which some 
have believed to be the effect of fistula in ano. In 
giving calomel either as a cathartic, or as an altera- 
tive, we have to use every precaution against saliva- 
tion, which is likely to be favored by the concurrent 
use of opium. 

As counter-irritants blisters are often employed with 
beneficial results, and they are generally applied di- 
rectly over the seat of pain, which is most likely to 
be in the pleura. But in using this remedy it must 
be borne in mind, that in case of high local excite- 
ment the stimulating effect upon the surface is some- 
times communicated by sympathy to the diseased 
parts beneath, thereby increasing the very difficulty 
we wish to remedy. Cupping and leeching are gen- 









Lectures on Fever. 171 

erally more efficient remedies, if the patient will bear 
them, and these are capable of being so graduated as 
to incur little risk of dangerous prostration. Sina- 
pisms are also used, and they have the advantage over 
blisters in their more prompt effect. As they leave 
no permanent soreness, they can be reapplied as re- 
quired. After all, it is doubtful -whether any thing is 
more valuable for this purpose than tincture of iodine. 
This may be painted over the whole chest, if neces- 
sary, and repeated as occasion requires, care being 
taken to guard against painful effects. As an adju- 
vant to, or substitute for all these, I recommend the 
application of dry cups over the spinal column. 

These are some of the means to be used in the 
treatment of pneumonic fever ; but it must never be 
forgotten that all are unavailable without the vigor- 
ous application of the antiperiodic treatment. This 
is to be pursued just as in other cases of periodic 
fever. Without this, paroxysm will follow paroxysm, 
until the vital powers are exhausted. Such a case 
will be called pneumonia, or more probably, if it 
prove fatal, typhoid pneumonia, for the term typhoid 
covers a multitude of professional sins nowadays ; but 
it is in fact a case of periodic fever, with the acci- 
dental concomitant of local lesions, the effects of fever, 
among the thoracic viscera. Without the fever these 
would have had no existence ; and with the fever act- 
ing as an exciting cause, the local affection cannot be 



172 Lectures on Fever. 



cured. For the want of this understanding of the 
case, great mortality has resulted from the prevalence 
of this form of fever in the South. 

No apprehension need be entertained that the anti- 
periodic treatment bestowed upon the fever will prove 
detrimental to the local disease, tighten the cough, 
impede the respiration, etc., as some authors warn us. 
These are mere figments of the imagination. The 
proper remedies for the constitutional disease are not 
likely in this, or in any other form of fever, to increase 
the intensity of the local lesions, which have been 
caused by the fever. On the contrary, every remedy 
having an influence toward the cure of the primary 
disease, must be expected to exercise a beneficial ef- 
fect over the secondary affection, upon the principle 
of removing the cause. It may be different in cases 
of pneumonia without any periodic complication, 
when antiperiodics are not indicated. In such cases, 
these remedies not only have no curative effect, but 
they nearly always produce unpleasant and injurious 
influences, and this is equally true in other forms of 
disease ; if there is no periodicity to cure, antipe- 
riodic remedies cause more or less distress, and tend, 
perhaps, to the increase of local disease.* 

But idiopathic pneumonia, occurring in subjects 
laboring under a strong predisposition to periodicity, 

* I ought to except, perhaps, the beneficial effects sometimes result- 
ing from the great sedative power of quinia. 




Lectures on Fever. 173 

from long exposure to its cause in what are called 
malarial districts, may have the effect to call the peri- 
odic movement into action ; and then we have a sim- 
ilar complication to that we have been considering, 
the local excitement being the primary, and the fever 
the secondary affection. This is a thing very likely 
sometimes to happen, but it is by no means peculiar 
to pneumonia. The periodic movement is called 
into action, in such subjects, by local irritation in 
almost any other part of the body, by rheumatism, 
and even by mechanical injuries. And when this is 
the case, the antiperiodic treatment is just as urgent- 
ly required as in idiopathic fever. The pneumonic 
inflammation arising from other causes may exist for 
several days before any signs of periodicity appear ; 
and in such cases I believe there is, in general, more 
active inflammation, and less of nervous irritation in 
the local disease ; and the treatment must be varied 
accordingly. Idiopathic pneumonia, whether occur- 
ring with such complication or not, is, I suppose, less 
likely to be accompanied by bronchitis, and especially 
by pleuritis, than when the disease appears as a local 
lesion of periodic fever. 

Pneumonic fever sometimes becomes epidemic 
among negroes on large plantations, often extending 
to several plantations in the same neighborhood, prov- 
ing exceedingly violent and fatal. In such epidemics 
the pneumonic affection is often imperfectly develop- 



174 Lectures on Fever. 

ed, and, indeed, can scarcely be detected, except by 
auscultation, before the patient is found to be in col- 
lapse, or the sinking stage. Few diseases are more 
fatal to the negro, in whom the vital powers are less 
energetic than in the white subject ; and the sinking 
stage of malignant disease proportionally more rapid. 
On account of this tendency to early prostration of 
strength, this form of the disease is generally called 
typhoid ; but it is not to be doubted that the debili- 
tated condition into which patients sometimes fall, 
even at so early a period, is not direct, but indirect ; 
being preceded by a stage of constitutional excite- 
ment above the standard of health. There is a stage 
in such cases, therefore, in which the contra-stimulant 
treatment is indicated, and required to be promptly 
and vigorously applied ; but it is of the utmost im- 
portance that it should be well timed. After the 
stage of collapse is initiated, the patient cannot bear 
depletion. Bloodletting, both general and topical, 
tartar emetic, nitrate of potash, and calomel, are all 
important remedies ; but quinia in this, as in other 
forms of the disease, is the most valuable of all our 
remedies. It should be given from the early incep- 
tion of the disease, as much as possible in the remis- 
sions ; and in sedative doses ; guarding against pros- 
tration by the use of carbonate of ammonia, sina- 
pisms, and the internal administration of chloroform. 
The nervous character of the disease, in its early 
stages, and the thoracic congestions accompanying the 






Lectures on Fever. 175 

chills or cold stages, call especially for the internal 
use of chloroform, which may "Be given several times 
a day in pretty full doses. 

Bat on account of the insidious character of this 
disease in the negro, there is sometimes a difficulty in 
bringing the cases under proper treatment in the first 
stages of the fever, when alone is it easily controlled. 
A negro, while at his usual labor, complains of debil- 
ity and loss of energy, and particularly of weakness 
in his limbs, which continue for an hour or two, and 
then pass away. The next day there is a recurrence 
of the same symptoms, only a little more severe ; and 
for several successive days the indisposition is repeat- 
ed without attracting much attention ; until finally he 
is quite prostrate, and soon afterward in the sinking 
stage of the disease, or stage of collapse. It can 
hardly be expected that in the beginning of such an 
epidemic prompt and efficient treatment will be ap- 
plied ; but after a few fatal cases have occurred, there 
can be little excuse for delays in the treatment which 
deprive the patients of almost their only chance of 
recovery. !No diseases, not even cholera and yellow 
fever, require earlier and more prompt attention than 
pneumonic fever. 

It may be proper, in this connection, to say some- 
thing of the remedial power of veratrum viride, es- 
pecially as it is in pneumonia, or the pneumonic form 
of fever, that it is more particularly recommended. 
The effect of this remedy in restraining the frequency 



176 Lectures on Fever. 

of the pulse is well established, and the evils arising 
from undue arterial excitement are so great, that high 
expectations in regard to the remedial efficacy of this 
article, in all such cases, have been raised in the minds 
of medical men. But it is true in this, as in many 
other cases, that expectations founded upon theoreti- 
cal views have not been fully realized. The medicine 
is a harsh one, and frequently the irritation it pro- 
duces in the stomach and bowels is seriously objec- 
tionable. No doubt it is a valuable remedy in skil- 
ful hands, but it must be' used with extreme care and 
caution, or injury will result from it. I have gener- 
ally preferred the aconite to answer the same indica- 
tions ; for, although it may be somewhat less prompt 
in its influence over arterial action, it -certainly exer- 
cises a more kindly effect upon the nervous system, 
and with less painful effects upon the mucous tissue. 
Indeed, we have few remedies which exert so much 
control over disordered innervation, and over cere- 
bra], spinal, and meningeal irritation. Its efficacy as 
an external application, in neuralgic affections, is also 
well established. But this is also a virulent poison, 
when given in too large quantity, and you cannot well 
be too cautious in its exhibition. I have generally 
used it in conjunction with tartar emetic, and the ni- 
trate of potassa ; and am inclined to the opinion that 
every dose of tartar emetic given in this disease 
should be accompanied with a dose of aconite, as its 
proper adjuvant remedy. 



LECTURE XL 

KKTKEIC FEYKE. 

This, like other, and more than most other, forma 
of fever, comes on in a slow and insidious manner, 
with exacerbations and intermissions : and. unless re- 
lieved by treatment, incrc sing in intensity from day 

lay : but in general several days els - : the 

sufferer is indue ncy oi the symptoms to 

call for medical aid. :s that he isthi 

ened with sc Be. The early paroxysms are 

very obscure, and frequently they are evidenced only 

sensations of debility in the limbs, and especially 
in the knees. TLese j ms are of short continu- 

ance, and the j Ford little signs 

ot sensations of disorder. Xor is it possible in this, 
any more than in the other forms of fever, to dc 
mine from the symptoms alone what is to become its 
peculiar character : or in what organs of the body its 
principal lc will be located. Indeed, the 

head, the chest, and the stomach, are more likel; 
exhibit the first signs of local lesion, and a weei 
more ] asses away before the real tendency of the fever 
in this respect can be fully determined. 



178 Lectures on Fever, 

Under the mysterious power of some epidemic in- 
fluence, or the operation of some other unknown 
cause, the symptoms after a while begin to indicate 
that the seat of the principal local affection is to be in 
the bowels. This appears to consist in congestion, 
and afterward inflammation of the mucous membrane 
of the intestinal canal, beginning in the lower por- 
tion of the ileum, and probably at the ileo-coecal 
valve. There is generally little evidence, at least in 
the early stages, that the muscular structures are at 
all involved, the symptoms not being those of enteri- 
tis. The soreness and pain are less, and the pulse is 
fuller and less frequent. These enteric symptoms are 
scarcely initiated before the signs of prostration ap- 
pear, which usually attend upon inflammation of the 
mucous tissues ; and the local lesion becomes a source 
of nervous irritation, as in symptomatic fever. The 
apyrexise, from this cause, become less distinct, and 
the case is apt to be declared one of continued fever. 

Whatever may be the case in other parts of the 
world, it can scarcely be doubted by any one accus- 
tomed to treat the fevers prevailing in the South, that 
the disease which I am now considering is a form of 
periodic fever. It begins as in other forms which are 
distinguished from each other, mainly, by their pecu- 
liar local lesions ; and like them it continues without 
any marked distinctive symptoms, until the febrile 
impression is made upon the mucous membrane of 



Lectures on Fever. 179 

the small intestines ; when the irritation thus pro- 
duced is reflected upon the constitutional disease. 
The effect is to increase and prolong the febrile 
excitement, in the same manner that symptomatic 
fever is produced by local inflammation. Other or- 
gans soon become also involved by sympathy. Nau- 
sea exists as in gastric fever; pneumonitis and bron- 
chitis, as in pneumonic fever ; and cerebral irritation, 
as in other cases of diseased mucous membrane of the 
intestinal canal, in chronic diarrhea, cholera infantum, 
etc. The debility, which in the early stages was 
temporary nervous depression, soon becomes perma- 
nent and progressive, from a want of proper assimila- 
tion of the food. The mucous tissues of the bowels, 
and the follicular and mesenteric glands, cease to 
perform their appropriate functions ; and the patient 
is continually sinking from the effects of inanition. 

A long train of perplexing and anomalous symp- 
toms ensue, which are so little under the control of 
remedial measures that some physicians have advised, 
as in despair of any successful treatment, that the 
only safe and hopeful course is, to abandon the pa- 
tient to that kind and sometimes efficacious agency, 
the vis medicatrix naturae. In general, however, 
there is no want of efforts on the part of the physi- 
cian to afford relief by active treatment. The indi- 
cations are so varied and complicate that there is 
more danger in this than in other forms of fever, of 



180 Lectures on Fever. 

doing injury to the patient by excessive, and especial- 
ly by inconsistent, medication. It is necessary that 
the bowels should be evacuated, but their mucous 
lining is now so susceptible to the action of purga- 
tives, that moderate sized doses are apt to cause hy- 
percatharsis. Opiates are indicated to control irrita- 
tion, and check alvine discharges, but they operate to 
arrest still further the flagging secretions. Stimulants 
are required to sustain the sinking strength, but they 
at the same time enhance the febrile excitement, and 
intensify congestion. Nourishing food is recom- 
mended for the same object, but digestion and assim- 
ilation are so far impaired that much of it passes 
along the intestinal tube undergoing only chemical 
changes, and increasing the irritation of the mucous 
membrane in its course. Thus is the system worn 
out and exhausted by the united agency of disease 
and treatment, and if at the expiration of twenty, 
forty, or sixty days, the patient has been able, by 
constitutional vigor and fortuitous aid, to survive, the 
disease may finally subside, and a slow recovery fol- 
low. 

As may be inferred from remarks already made, 
the symptoms in enteric fever are multifarious. In 
the early stage, we have the usual daily paroxysms, 
and the usual increase in severity from day to day ; but 
after a certain time, longer or shorter according to the 
violence of the disease, the local lesion in the mucous 



Lectures on Fever. 181 

membrane of the bowels becomes established, and then 
the paroxysms are less distinct ; and the apyrexial 
period is more irregular and less complete. From 
this time the tongue becomes coated, with reddened 
edges, the appetite is gone, the bowels are loose, or 
easily moved, the shin becomes hot and dry, the 
cheeks flushed, and the pulse moderately accelerated. 
There is, also, headache, pain in the back and limbs, 
restlessness, wakefulness, nausea, abdominal pains, 
tympanitis, a gurgling sound in the bowels upon be- 
ing pressed or moved, cough with symptoms of bron- 
chitis, and scanty and high-colored urine. Then the 
tongue becomes dry, and of a brownish color, deglu- 
tition difficult, the abdomen distended ; petechise, 
vibices, rose-colored spots and sudamina appear upon 
the skin ; the patient suffers with stupor, delirium, 
and deafness; the eyes are injected and expression- 
less ; the tongue dry and tremulous, often black, 
hard, and. swollen ; sordes collect upon the teeth ; 
the pulse is more enfeebled ; subsultus and picking 
of the bedclothes begin ; the urine is either not se- 
creted or retained ; involuntary discharges from the 
bowels take place ; there is sometimes hemorrhage 
from the nose, mouth, and anus ; the surface becomes 
cool, moist, and clammy ; the body slides down in 
the bed ; hiccough sets in, and the appalling scene is 
ended by death. 

Some of the symptoms which give hope of recov- 



182 



Lectures on Fever. 



eiy are, the gradual cleaning of the tongue about the 
edges, with a more healthy secretion of saliva ; great- 
er fulness of the pulse ; improvement in mental vig- 
or ; subsidence of abdominal soreness and distension ; 
more healthy alvine discharges ; sound and refreshing 
sleep ; disappearance of febrile action, etc. But if 
the disease has been of long continuance, the conva- 
lescence is slow and tedious. The tone of the digest- 
ive organs has become so much impaired, that the 
food which is craved by improving appetite is imper- 
fectly digested, and the irritation produced upon the 
still tender bowels causes troublesome diarrhea, or 
perhaps invites back the periodic movement, and we 
have what is called a relapse ; making it necessary to 
repeat much of the previous treatment. And it is 
not unfrequently the case that such relapses prove 
more difficult of cure than the original attack. They 
are nearly always complicated with periodicity. 

The post-mortem appearances of disease, as in other 
forms of fever, are less distinct than might have 
been expected from the long-continued severity of 
the symptoms. The mucous membrane of the intes- 
tinal canal presents more or less of a morbid as- 
pect throughout ; but most distinctly in the ileum, 
and in the neighborhood of the ileo-ccecal valve. 
It extends, also, in somewhat less degree, to the 
colon and rectum, on the one hand, and to the duo- 
denum and stomach, on the other. Even the oesopha- 



Lectures on Fever. 183 

gus and pharynx are not exempt, nor the mucous 
membrane of the mouth and nasal passages. The 
mucous follicles are of course more or less diseased ; 
the elliptical patches of Peyer, and the solitary glands, 
are now said to be always enlarged, hardened, and 
sometimes ulcerated. But these are very minute or- 
gans, and notwithstanding their enlargement in this 
disease, it is only very recently that even their exist- 
ence has been discovered by autopsic examinations ; 
although enteric fever has probably prevailed for 
many centuries. The mesenteric glands are said to 
be similarly affected. The liver, spleen, and kidneys 
are also implicated, as are, indeed, to some extent, all 
the organs and tissues, in proportion, perhaps, to the 
intensity of the disease, and the period of its continu- 
ance. Perforations of the intestines are said some- 
times to exist, and generally from ulceration of the 
glands in some portion of the ileum. This intestine 
seems, indeed, to be the primary and principal seat 
of the prominent local lesion, in enteric fever. 

Xow, I suppose you will have had no difficulty in 
perceiving that the disease, of which I have given a 
hasty and succinct description, is none other than 
what is now called typhoid fever : a disease about 
which such voluminous publications have been made 
within a few years past. It is not a new disease in 
any thing but the name, and this is as inappropriate 
as any that could well have been chosen. Nor can the 



184 Lectures on Fever. 

fact of the diseased glands, so lately discovered, and 
about wliicli so much ado lias been made, be consid- 
ered any more distinctive of the disease than the 
morbid condition of the mucous membrane, so long 
observed. Indeed, there are good reasons for believ- 
ing that the latter is the primary, and the former a 
secondary affection consequent upon it. It is diffi- 
cult to conceive of such a diseased condition of the 
mucous membrane, sometimes extending from the 
lips to the anus, without the production of disease in 
the follicular glands, which are placed in its folds, or 
in close connection with it. 

We have been told that the inflammation and tu- 
mefaction of Peyer's glands are invariably found, and 
therefore we ought to infer that these are as much 
characteristics of the disease as are the variolous pus- 
tules of small-pox. But it has since been denied, 
upon good authority, that the existence of disease 
in these glands is a constant condition ; and if 
a single case can exist without the local affection, it 
must be very certain that it cannot be the cause of 
the fever. Further, it must be considered that it is 
only in the fatal cases that these conditions can be 
ascertained ; and if there be exceptional cases at all, 
these may be supposed to be more numerous in the 
instances of recovery, or the least violent grades of 
the disease. No good reason can be given why Pey- 
er's glands are diseased before the appearance of the 






Lectures on Fever. 185 

fever ; nor even afterward during all its continuance, 
except tlie sensitiveness of the intestinal canal to the 
influence of cathartics, and the depressing character 
of the disease, both conditions pointing directly to the 
more extended lesion of the mucous membrane. Be- 
sides, we should be justified in supposing that P ev- 
ert glands, if they were the seat of the principal 
local lesion, might become diseased to the extent 
which has been observed, without there being any 
considerable morbid condition of the mucous mem- 
brane, or of the solitary follicles. But we find that 
in all cases, both these tissues are involved in disease, 
and that the mucous membrane is implicated to a far 
greater extent than would seem to be necessary, were 
its condition dependent upon the disease first affect- 
ing Peyer's glands. While these glands exist only 
over a comparatively small space, the mucous mem- 
brane is diseased throughout its whole extent ; and it 
seems more reasonable to attach the greater import- 
ance to the more extended and important lesion. For 
these and other reasons, which the limits of a lecture 
will not allow me to discuss, I conclude, that the prin- 
cipal local lesion in enteric fever is not in the ellip- 
tical patches or follicles of the ileum, but in the more 
important and extended tissue, the mucous mem- 
brane of the intestinal canal; and that the diseased 
follicles which sometimes, but not always, appear, and 
to which such undue importance has been attached, 



186 



Lectures on Fever. 



become so diseased as a consequence of the diseased 
mucous membrane. The same is probably true also 
of the mesenteric glands. 

In regard to the causes producing this determina- 
tion of morbid action to the bowels, we know noth- 
ing more than we do of the causes of local lesions in 
other forms of periodic fever. We know only from 
observation that they are, in all cases of severity, suf- 
ficiently prominent in some particular organ of the 
body to give a name to the disease, distinguishing it 
from other forms of fever ; but we do not know the 
reason why, any more than we do why the character- 
istic lesion of small-pox should be in the skin. En- 
teric fever, however, is supposed to prevail mostly in 
cities and crowded habitations, and hence it has been 
attributed to the influence of exhalations, or secre- 
tions, from the human body ; but the disease is not 
unfrequently met with in high and dry country local- 
ities, where the population is sparse, and where the 
atmosphere is apparently pure and wholesome. Con- 
tagion has been assigned as a cause, but there is no 
certainty that it ever exists. The doctrine, in regard 
to this and many other diseases, is supported only by 
the fact, that the fever has sometimes seemed to 
spread from a single case; but in general no such 
spreading takes place, and instances are numerous in 
which cases occur in isolated positions without such 
exposure. In small-pox, which is a proper example 



Lectures on Fever. 1ST 

of contagions disease, these anomalies do not occur. 
Whenever two or more cases of this disease are found 
in the same locality, therefore, it is safer to conclude 
that they have originated from a common cause, than 
that one has produced the other without our know- 
ing, as is often the case, how the first had its origin. 

In both enteric and gastric fever, it has been ob- 
served that persons who have once had them are not 
liable to suffer from a second attack, at least not se- 
verely. As this is true of some contagious diseases, 
as small-pox and measles, it has been inferred from 
this similarity that these fevers are also contagious. 
But the cases are not parallel. Persons who have 
once suffered from gastric and enteric fevers are not, 
in fact, wholly exempt from them afterward. They 
are only placed in the category of those who are sub- 
ject only to the milder grades of endemic and epide- 
mic fevers. I have had some experience of this in my 
own person. Many years ago I suffered from a se- 
vere attack of yellow or gastric fever, when the dis- 
ease was prevailing as an epidemic ; and in the several 
epidemics of this disease to which I have since been 
exposed I have never escaped an attack, and have 
had all the symptoms of the mild grade of the dis- 
ease. The truth of this matter is, according to all 
my observations, that those who have once had vio- 
lent attacks of periodic fever, with serious lesions of 
any of the vital organs, rarely ever experience a re- 



188 



Lectures on Fever. 



turn of the same form of the disease of a violent anc 
dangerous character. This is an acclimatizing pro- 
cess, well understood and acknowledged in the South. 
It is a partial protection only, and not such as is se- 
cured by an attack of any one of those contagious 
diseases which, as a general rule, affect the system 
but once. No one, not a native of the climate, can 
consider himself secure from a severe attack of peri- 
odic fever, until he has experienced one ; nor does the 
suffering from one of its distinctive forms afford an 
immunity from another, although it undoubtedly ex- 
ercises a modifying influence. Those who have had 
gastric fever are certainly liable to pneumonic fever, 
and sometimes to enteric fever ; but the latter form is 
not common, and does not often become epidemic in 
this climate. Sad mistakes are made in regard to 
this matter. Immigrants, after residing in the South 
several years without suffering from periodic fever, 
are apt to consider themselves exempt, by reason of 
their long residence. Under this belief they are will- 
ing to incur the risk of any exposure, and they often 
pay dearly for their ignorance of the subject. 

That enteric fever is a periodic disease, with cer- 
tain local lesions as its consequents, is evidenced by 
the same facts upon which I have depended to prove 
to you, that gastric and pneumonic fevers are of the 
like character. In these and other forms of periodic 
fever, as I have already more than once remarked to 



Lectures on Fever. 189 

you, the fever, as a general and constitutional disease, 
always exists for several clays before there are any 
positive signs of the principal local lesion. These 
come afterward ; and in no other form of fever is it 
more certainly the case than in the enteric. All 
writers on the subject virtually make this acknow- 
ledgment ; and yet, strange to say, they insist upon 
the local disease, not of the mucous tissue, but of 
Peyer's glands, as being essentially the disease to be 
treated, and not the constitutional febrile affection. 
The disease is called typhoid, principally for the rea- 
son, I believe, that the strength of the patient fails at 
a comparatively early period, and the febrile action 
continues for a long while. Xow, that the strength 
should really fail, because of the suspension of the 
functions of the mucous membrane, of the mesenteric 
glands, and even of the glands of Peyer and Brun- 
ner, whatever they may be, seems natural enough, as 
the system is thereby deprived of its accustomed nu- 
trition ; but that the disease is one of actual debility 
from the commencement, is not more true of this than 
of other forms of periodic fever. In this climate it is 
not true of any. Debility ensues from an exhaustion 
of vital energy by previous excitement, and second- 
arily, from want of proper nutrition ; and the fever is 
perpetuated by the irritation of its local lesions. 

The diagnosis of enteric fever cannot, of course, be 
made out in its early stages, for the plain reason that 



190 Lectures on Fever. 

its characteristic lesion is not formed ; until which, it 
does not differ from other forms of periodic fever to 
such extent as to enable us to give a confident diag- 
nosis. We can sometimes judge pretty correctly, 
however, from the character of the fevers prevailing, 
or from epidemic influences, so called. "We know of 
no symptom in any case which gives us certain assur- 
ance that Peyer's glands are especially diseased, until 
we come to the autopsy. If the patient survive, we 
are without proof of the existence of this affection ; 
for, the use and purpose of these glands not being 
known, we cannot tell what results follow the suspen- 
sion or derangement of their proper functions. But 
we do know something of the effects of the irritation, 
inflammation, and suspended function of the mucous 
membrane of the bowels, and also of their influences 
by sympathy upon other organs of the body. 

The treatment proper in the early stages, as may 
be inferred from the description I have given you of 
the disease, need not differ from that adopted in other 
forms of periodic fever. Indeed, it would seem to be 
quite absurd to recommend any other, while we can- 
not discriminate between this and other forms. The 
antiperiodic treatment will, of course, be adopted, and 
prosecuted with a vigor proportioned somewhat to 
the expected violence of the disease. Whenever this 
is properly applied, and at the proper time, there will 
be no enteric or typhoid fever at all ; for the sinrple 



Lectures on Fever. 191 

reason that the fever will be arrested and cured be- 
fore the characteristic local lesions are formed. Even 
the irritations and congestions existing in the lungs, 
brain, stomach, etc., require little attention in the in- 
choate stage, as they are merely the results of disor- 
dered innervation, and under the influence of active 
antiperiodic treatment, generally temporary. They 
belong to all the forms of periodic fever, and are not 
among the distinctive characteristics of any. As 
nervous affections, they are nevertheless more or less 
distressing, and may in general be relieved for the 
time, by the internal administration of chloroform. 
But should the fever continue, recurring from day to 
day with constantly increasing violence, then we must 
expect that the prominent local affection, which is to 
give the disease character and name, will, under epi- 
demic, or some other mysterious influence, become 
established ; and then we have an important and 
always dangerous complication to manage — a local 
disease which has a constant tendency to increase and 
perpetuate the fever, through the influence of an 
active nervous sympathy. 

The diseased condition of the mucous membrane 
having become thus established, the case presents new 
indications and increased difficulties. The disease 
differs from gastric and other forms of fever in its 
slow and persistent progress ; and the greater suscep- 
tibility of the bowels to the action of cathartics makes 



192 Lectures on Fever. 

it necessary to employ this class of remedies with 
greater caution than in other forms of fever under 
like circumstances. Castor oil, in combination with 
turpentine, is, perhaps, among the best ; the former 
being one of that class which excite the peristaltic 
action without much local irritation, and the latter 
being peculiarly adapted, as a local remedy, to the 
diseased mucous membrane. Indeed, the turpentine 
is among the most valuable of all the remedies used 
for the relief of this local affection, and its good effects 
are sometimes enhanced by the addition of balsam 
copaiba in small doses. Sugar of lead has been re- 
commended to restrain diarrhea ; also the tannic acid 
and other astringents ; but there is probably no rem- 
edy so valuable as strychnia to meet this indication. 
The control which this remedy exercises over the 
movement of the bowels caused by irritation of the 
mucous membrane, as in this disease and in common 
diarrhea and cholera, is very decided and reliable. 
Tartar emetic cannot be freely administered after the 
local lesion is fully established, because of its irritat- 
ing influence over the mucous membranes, and the 
best sedative substitutes are bathing and refrigerant 
enemata. Frequent sponging the surface with warm 
whiskey or vinegar, exercises at once a cooling and 
soothing influence, and it probably produces useful 
effects upon the mucous membrane of the bowels, by 
reason of the close sympathy between the bowels and 
skin. 



Lectures on Fever. 193 

I am inclined to believe that this is one of the 
forms of fever in which great injury is frequently 
done by the too free administration of opium. In the 
early or irritative stage of the fever it is doubtless 
useful, although chloroform may be considered a bet- 
ter and safer remedy ; but when the local lesions have 
become well established, the secretions are always 
partially suspended ; and this difficulty is apt to be 
seriously increased by the exhibition of opiates. Cal- 
omel now becomes an important remedy, on account 
of its influence over these glandular obstructions ; but 
to avoid hypercatharsis, it should be given in very 
small doses, and not in conjunction with opium. 
Bloodletting is principally useful in the early stages, 
but at later periods, topical bleeding may sometimes 
be resorted to with excellent effects, especially about 
and below the umbilicus. Sinapisms and poultices, 
and the two combined, are often very useful upon the 
abdomen and spine. Dry-cupping the spine is also 
employed with good effect, as is also the practice of 
clapping the spinal column. Dry and red tongue, 
and especially the flaking off the coating in patches, 
indicate the use of turpentine, as do also the symp- 
toms of tympanitis. The sweet spirit of nitre and 
Hoffman's anodyne are very composing in their ef- 
fects, when nervous symptoms prevail in the advanced 
stages. 

Quinia is sometimes used as a tonic in this disease. 




lectures on Fever. 



but I doubt whether it contains much of the tonic 
quality of Peruvian bark. It is no doubt useful as an 
antiperiodic, and should be given as in other forms of 
periodic fever. In most cases, it is probably essential 
to the cure, but in the later stages it should not be 
given in large doses. At all times, the dose may be 
lessened and the tonic effect increased by the addition 
of arsenic. The carbonate of ammonia, as an excit- 
ant, is mostly to be preferred to alcoholic fluids. 
Effervescing mixtures are grateful and serviceable, 
and may be given in small quantities very often. 
Nourishing food is always necessary, but it must be 
carefully considered that the power of digestion is 
much enfeebled, and that every particle of food, of 
whatever kind, which passes through the bow r els un- 
digested, increases the already too great irritation. 
The free use of mucilaginous drinks cannot always 
be indulged in with safety on this account, and the 
indiscriminate and unlimited use of even such bland 
articles of diet must be condemned. The object of 
food is to nourish and support the body; and that 
kind is best which is most easily digested, and which 
supplies the largest amount of nutriment in a given 
bulk. I am inclined to believe that the best for gen- 
eral use is fresh milk which has been well boiled as 
soon as taken from the cow. It is more soothing than 
gum-water, while it affords an ample supply of easily 
digested nourishment, and is, withal, a good vehicle 



Lectures on Fever. 195 

for the exhibition ot stimulants. It is important, 
however, that the milk should be boiled, and it is al- 
ways better to be boiled while fresh, before the lighter 
particles have time to rise toward the surface. Milk, 
used in this way, is both nutritious and medicinal in 
all intestinal irritations ; as is also the gluten of flour, 
entirely divested of the admixture of starch. I com- 
mend these two articles of diet, to your constant con- 
sideration. 



LECTITEE XII. 

EXANTHEMATOUS FE VEKS. 

Before dismissing the subject of fever, it is proper 
that I should say something of that peculiar class 
called eruptive fevers. The particular forms which 
will engage our attention are, small-pox, measles, and 
scarlatina, as proper representatives of the whole class. 
To these are sometimes added erysipelas, plague, var- 
icella, roseola, dengue, urticaria, and the vaccine dis- 
ease. Hooping-cough and mumps have also been 
considered kindred affections, not specially affecting 
the skin. 

The eruptive fevers begin their course with the 
usual symptoms of fever arising from whatever cause, 
and in due time they present their characteristic local 
lesions with wonderful uniformity upon the surface of 
the body. There are many points of resemblance in 
the different forms, just as there are, as we have seen, 
in the various fevers specifically affecting other and 
internal organs of the body; and we are told that 
until a recent period the eruptive fevers were consid- 
ered only as variations of one and the same disease. 



Lectures on Fever. 197 

The truth is, however, that they are as easily diag- 
nosticated, one from another, as other forms of fever ; 
and even more so, because their characteristic lesions, 
our principal guide in all fevers, are in these, unlike 
all others, both visible and tangible. We may con- 
clude, therefore, that they who considered them to be 
identical, either had not seen the different forms at 
all, or that they were only very superficial observers 
in pathology and diagnosis. 

These fevers are supposed to be caused by conta- 
gion, a mysterious and impalpable influence emanating 
from the human body while suffering from the dis- 
ease, and, like the causes of other forms of fever, 
known only by its effects. All this is, no doubt, true, 
but it is equally true that eruptive fevers have some- 
times appeared, as all must have done originally, 
without exposure to such contagious emanations. 
Their spontaneous origin, so called, has not only been 
proved, but we find the epidemic influence producing 
them so strong, that their peculiarities are impressed 
in some degree upon other febrile affections, and even 
upon healthy subjects who enjoy an exemption from 
having once had the disease. 

As we are not permitted to question the truth of 
the axiom, like causes produce like effects — in other 
words, that a particular effect is always due to the 
operation of the same cause — we must conclude that 
there are other sources of these causes of contagious 



198 Lectures on Fever. 

disease than the human body ; that whenever these 
diseases become epidemic, this mysterious essence 
pervades the atmosphere, and that it exists in varying 
intensity in different localities, causing more or less 
of diseased action, such as is peculiar to the prevailing 
disease, in all subjects who are in a predisposed con- 
dition and exposed to the epidemic influence. As to 
the nature of this cause we know nothing whatever ; 
nor can we have any conception of the differences ex- 
isting in the various causes of febrile disease, differ- 
ences which determine the character of the effects 
produced. As in the case of attraction of gravitation, 
our knowledge is confined to results. 

"When any one of these eruptive fevers is prevail- 
ing as an epidemic, it is not uncommon to meet with 
some of its distinctive symptoms, febrile, eruptive, or 
anginose, without such full development of the dis- 
ease as will preclude its recurrence at another time, 
or such as will justify the opinion that the patient, 
having previously had the disease, has now suffered a 
second attack. These are effects of epidemic influ- 
ence, operating upon the system independently of 
personal contagion, and showing that the morbid ef- 
fect of a specific cause may be produced in an imper- 
fect degree in subjects who are protected against its 
entire and legitimate operation. Hence the anoma- 
lies observed in this class of fevers. In measles we 
have the eruption without the catarrhal symptoms, 



Lectures on Fever. 199 

and vice versa / in scarlatina, the eruption without 
sore-throat, and the reverse; and in small-pox, the 
umbilicated pustule either with or without fever, and 
each case without the contagious power belonging to 
the disease simulated. 

The rule of authors is, that the system is not liable 
to a second attack, but there are many exceptions. 
In general, as in other forms of fever, the immunity 
is somewhat in proportion to the violence of the dis- 
ease, or at least to the fulness of its constitutional 
development. But this does not always hold true. 
Confluent small-pox is sometimes succeeded by vario- 
loid. An apparently perfect vaccine disease may be 
followed by one or more repetitions of it, before the 
virus ceases to produce its proper effect. Measles and 
scarlatina are, perhaps, equally apt to reappear, until 
the system will no longer respond to the influence of 
the contagion upon it. 

This immunity from repeated attacks of contagious 
disease, even with the exceptions referred to, is a hap- 
py provision of nature for the preservation of the 
human race ; but no satisfactory explanation has yet 
been given of it. The recent attempts to account for 
it on chemical principles, beside being destitute of 
proof, seem to my mind irrational, and in conflict 
with the laws of vitality. It is, in fact, a revival of 
the humoral pathology, without better reasons in 
support of it than were given by its ancient advocates. 



200 Lectures on Fever. 

To suppose the blood, while circulating in the system, 
to be capable of those chemical changes — fermenta- 
tions — to which dead animal fluids are subject out of 
the body, is to admit a principle which leads to the 
inevitable denial of all vital force, and the consequent 
disorganization and decay of both fluids and solids in 
the living body. 

While we find animal and even vegetable life sus- 
tained in the living stomach, and resisting the strong 
solvent power of the gastric secretion, as well as a 
concentration of those chemical agencies so destruc- 
tive to dead animal matter, we can hardly suppose 
that the vitality of the circulating blood is of so feeble 
a nature as to admit of spontaneous decomposition in 
living bloodvessels ; and this at the same time that it 
is the basis of every form of physiological support, 
such as nutrition, secretion, innervation, and calorifi- 
cation. The observations of every day convince us 
that there is a vast difference between the blood in 
the living body and the blood out of the body, as re- 
spects its susceptibility to the action of chemical 
agencies ; and in the absence of all proof to the con- 
trary, it is quite safe to believe, as we have been 
taught to believe since the overthrow of the humoral 
pathology, that chemical agency now, as formerly, so 
much relied on, has no existence in fact. We may 
still be permitted to cling to the belief, that the phe- 
nomena of physiology and pathology find a control- 



Lectures on Fever. 201 

ling power in the vital principle, ^Ve are justified, 
at any rate, in assuming the negative in the contro- 
versy, and in calling upon those who deny the para- 
mount agency of vital power, substituting chemical 
action in its stead, to verify and substantiate their 
assumption by proof. 

In the origin and progress of these eruptive fevers, 
we have something that is more definite and reliable 
than in regard to other forms of fever ; for, although 
we are quite as ignorant of the nature of the cause, 
and the mode of its operation, we do know its usual 
source, something of the period of time it requires for 
producing its proper effects, and the character of those 
effects. But we cannot account for the fact, that the 
contagion appears to lie dormant in the system dur- 
ing the period of incubation, or explain why it is that, 
when it begins to act, it should first produce a de- 
pression of vital power, followed by the morbid reac- 
tion of fever. And we are equally at a loss to know 
why, in this case, the characteristic lesion, in due time 
produced, should be in the form of a peculiar cutane- 
ous affection, in all respects the same as that in the 
case whence the contagion was derived. These things 
are just as much hidden from our view as are those of 
a similar character which appertain to the origin and 
progress of gastric, enteric, and pneumonic fever ; 
but they corroborate our general views respecting the 
formation of local lesions as the effect of idiopathic 



202 



Lectures on Fever. 



fever. Were the eruptions in these cases the primary 
effects of contagious influence, we should probably 
have fever too ; but this would then be caused by lo- 
cal irritation, and the fever would, of course, be symp- 
tomatic. 

In exanthematous fevers the febrile action, which 
constitutes the earliest appreciable stage of the disease, 
is so closely assimilated to that of other forms of idio- 
pathic fever, that we are not able to distinguish them, 
one from another, with any degree of certainty. In 
each there are, indeed, some distinctive peculiarities, 
but these are more or less common, in some degree, 
to other forms of febrile disease; and they cannot be 
relied on as bases of diagnosis. But whenever either 
disease becomes epidemic in a particular locality, our 
suspicions are aroused by every sign of fever ; and 
then, by close observation of its early peculiarities, 
we are enabled to warn the friends of the patient of 
the probable character of the disease. In sporadic 
and unexpected cases, however, the appearance of the 
eruption generally affords us the earliest means of 
diagnosis. It is, therefore, very important to be able 
to discriminate these eruptions in their early stages. 

In their inception, therefore, and in their progress 
up to the development of their peculiar local lesions, 
exanthematous fevers bear a close resemblance to 
other forms of fever, with daily exacerbations and re- 
missions. This periodic movement is generally of 



Lectures on Fever. 203 

sufficient distinctness to induce physicians to adopt in 
the beginning the antiperiodic treatment, and especi- 
ally, should there be great uncertainty about the char- 
acter of the disease. In many cases there is. indeed, 
a periodic complication "which makes this treatment 
highly proper and useful ; but it must not be expected 
that it will arrest the disease. No plan has been dis- 
covered by which this can be done. The eruptive 
stage necessarily follows, and when this appears there 
is no longer anv doubt as to the character of the dis- 
ease. It is then full time that we should seriously 
consider the peculiarity of treatment required. 

As smallpox is the gravest and most fatal of these 
forms of fever, so is it most important to adopt for its 
treatment proportionally prompt and active measures. 
Remedies must be applied upon the general principles 
of practice, however ; and could we always know, 
from the beginning, that the case is one of small-pox, 
the mortality attending upon this dreadful disease 
might be materially lessened. ~We might, from its 
very inception, begin to anticipate the grave and fatal 
symptoms which are so certain to ensue, and to pro- 
vide, prospectively, for an emergency which must be 
met and combated. 

Authors divide the course of the disease into three 
stages — fever, pustulation, and decline. The first 
stage, as already intimated, is to be treated very much 
as other forms of fever; but, I repeat, if we are ex- 



204: Lectures on Fever. 

pecting to encounter so serious a disease as small-pox, 
we shall do well to make our preliminary treatment 
proportionally active, even although it may happen 
that the early symptoms are not of great severity. 
This treatment must, of course, be antiphlogistic and 
evacuant, and in degree proportioned somewhat to 
the vigor of the constitution and the intensity of the 
prevailing epidemic. In habits decidedly plethoric, 
free general bloodletting is advisable, and the earlier 
it is used, the better will be our ability to control the 
dangerous symptoms of later stages. The same is 
true in this as in other grave forms of fever ; blood- 
letting in the early stage secures to us great advan- 
tages in the subsequent treatment. The inflammatory 
tendency is, by this means, so far subdued, as to very 
much lessen the evils arising from violent local lesions ; 
while at the same time the general febrile action is in 
some degree subdued. 

The next consideration is, to relieve the digestive 
organs of all causes of irritation by the use of emetics 
and cathartics. In this as in most other diseases, the 
stomach is always best evacuated by the use of emet- 
ics. The early cathartics should be active and effi- 
cient. Calomel may be given in scruple doses, and 
this may be followed by castor oil after a proper in- 
terval, so that both may act simultaneously. "While 
all this is being done, we must guard the patient 
against undue febrile excitement by the use of anti- 







Lectures on Fever. 205 

monials, cold bathing, fresli air, and sometimes by re- 
peated bloodletting. Care should be taken also that 
the circulation be properly equalized by the use, if 
necessary, of sinapisms freely applied to the extremi- 
ties, and by hot pediluviae. All this, you will ob- 
serve, is to prepare the patient, as in the treatment of 
all fevers, for the expected local lesion ; for the erup- 
tive stage, or stage of pustulation. This is to be mod- 
erated in extent by all possible means, that symptom- 
atic fever may not ensue as an effect of the local irri- 
tation, and that we may preserve, as far as possible, 
the healthy functions of the skin. 

Upon its first appearance, the eruption resembles 
recent flea-bites. It is in florid points, which soon 
have a hard base sensible to the touch. These, as 
they enlarge, form vesicles upon the surface, and come 
to maturity in about eight days in a peculiar pustule, 
having in most cases a depression or umbilication in 
the centre. If the eruption should be very thick, 
many of the pustules coalesce from mere proximity, 
and in that event the disease is called confluent small- 
pox, indicating the more dangerous grade of the dis- 
ease. The mucous tissues become involved more or 
less in the local affection, producing inflammation in 
the mouth and throat, and in some cases extending 
the morbid action to the stomach and bowels. The 
general fever abates in violence as the eruption ap- 
pears, and then we have to contend principally with 



206 Lectures on Fever. 

the nervous irritation and the suspended functions of 
the skin and mucous membranes. It is during this 
eruptive stage that a peculiar odor is exhaled from 
the surface of the body. 

The symptoms have now become more complicated, 
and the treatment more difficult than before ; but if 
the physician keep constantly in view the general 
and well-established principles of practice, which in 
no disease are ever to be lost sight of, he cannot go 
far wrong. He must consider the danger to the pa- 
tient of passing from the sthenic to the asthenic con- 
dition, and modify his contrastimulant practice ac- 
cordingly. Tepid sponging, and especially with wa- 
ter slightly acidulated, is often a better means of re- 
frigeration in the later stages than cold bathing ; and 
care must be taken not to continue the use of cold 
applications, or the exposure of the patient to cold 
air, beyond the proper time, merely because these 
remedies have been so highly recommended in the 
treatment of small-pox. They are highly valuable, 
but in this, as in other diseases, only when properly 
timed. 

Care must be taken that the strength of the pa- 
tient be not prostrated by repeated watery stools, 
which are best prevented in this, as in other febrile 
affections, by a proper choice of cathartics. Calomel 
and aloes are among the safest articles of this class, 
and in case of watery dejections to an alarming ex 



Lectures on Fever. 207 

tent, a combination of aloes and myrrh, is useful. It 
is always desirable that this evil should be controlled 
without the use of opiates, which are only temporary 
and frequently injurious in their effects. Nothing is 
more important, however, than the use of cathartics, 
to the extent of relieving the bowels, daily, of mor- 
bid and irritating excretions. 

The sinking of the vital powers, so justly to be 
feared, must be treated, of course, by corresponding 
stimulation. The carbonate of ammonia is the most 
important excitant for immediate effect ; and the min- 
eral acids and iron the most suitable for permanent 
support. Sudden, and alarming prostration requires 
the liberal use of sinapisms. The energy exerted by 
these in reviving nervous power is wonderful ; but 
they must be applied extensively, and often renewed. 
Secondary fever sometimes becomes troublesome, as 
the eruption subsides ; and to combat this, contrasti- 
mulant measures may have to be resumed. But this 
seldom happens when the previous stages have been 
judiciously treated, and especially if bloodletting has 
been used previously to the appearance of the erup- 
tion. Scars on the face may in a measure be prevent- 
ed by the application of collodion, iodine, nitrate of 
silver, mercurial ointment, or almost any thing which 
will shield the pustules from the contact of air. 

The fever of measles is generally accompanied by 
more or less of catarrhal symptoms, with suffusion of 



208 Lectures on Fever, 

the eyes, coryza, sneezing, sore throat, and husky 
voice. The eruption may be expected about the 
fourth day, but sometimes it appears later, even so 
late, it is said, as the tenth day. The eruption first 
appears in small red points, very like that of small- 
pox, but without the hard base, although slightly ele- 
vated. It is attended by considerable itching and 
burning, and it frequently extends to the fauces. This 
also becomes confluent, but in patches of a crescent 
form, with vacant spaces between. Fever attends 
the eruption, and sometimes increases, but the patient 
is generally relieved in some degree of the preceding 
oppression and inward distress. On the fourth day 
of the eruption it begins to subside, and is followed 
by furfuraceous desquamation. 

The treatment, as in small-pox, consists in the use 
of aperients and low diet, together with such exter- 
nal applications as tend to moderate excessive heat 
and equalize the circulation. But it must be borne 
in mind that the asthenic condition is more readily 
induced by depletion in this disease, and especially 
by active catharsis, and large doses of calomel. Blood- 
letting is even better borne in most cases than purg- 
ing ; and for reducing redundant heat it is generally 
better to depend upon evaporation from tepid ablu- 
tions with water and vinegar, than upon cold bath- 
ing. Soothing mucilage may be applied to the eye- 
lids, and should there be much bronchial irritation, 



Lectures on Fever. 209 

or pneumonic inflammation, we must resort to the use 
of cups, leeclies, and antimonials with nitrate of po- 
tassa and aconite, as in the treatment of pneumonia. 
An undue depression of vital power must be met by 
a free use of ammonia and sinapisms. If attended 
by alarming congestion, chloroform may be freely 
administered by the mouth. 

Unfavorable symptoms are apt to be accompanied 
by repelled eruption, calling for the use of emetics, 
sinapisms, and warm bathing. [Nearly always, how- 
ever, the eruption is repelled either by derangement 
of the digestive organs, or by the sudden exposure to 
cold. It is, therefore, important to consider that, al- 
though refrigeration and catharsis are necessary rem- 
edies, they are, when injudiciously managed, abun- 
dant sources of mischief. For this reason, these 
measures are by some almost entirely omitted, and 
what are called the sequelse of the disease are apt to 
appear in consequence. These are more difficult of cure 
than the original complaint, and they lead, not unfre- 
quently, to fatal results. The principal difficulties 
are, hepatic torpor, hypertrophy of the liver and 
spleen, congestion in some of the mucous tissues, 
pneumonitis and bronchial irritation. These are best 
relieved by a suitable course of alteratives, having in 
view the nature and seat of the local affection, fol- 
lowed by tonics. Mercurial and iodine preparations 
are most relied on. In prescribing mercury in such 



210 Lectures on Fever. 

cases, I generally give preference to the corrosive sub- 
limate over calomel, as at once more mild and effici- 
ent, and as less likely to produce ptyalism. Mercu- 
rial salivation in such cases, especially in children, is 
always injurious, and sometimes proves fatal. You 
cannot well be over-cautious, therefore, in the admin- 
istration of calomel, especially if given in conjunc- 
tion with any of the preparations of opium. Iron 
and the mineral acids are the best tonics. Quinia is 
often used as such, and it is, doubtless, a valuable rem- 
edy in these cases, but its efficacy depends mainly, I 
suspect, upon its antiperiodic and contrastimulant 
qualities. 

Scarlet Fever, the remaining exanthem I propose 
to consider, comes on with many of the same symp- 
toms as the others, but there is generally sore throat, 
great redness of the mouth and throat, without ca- 
tarrh or inflammation of the eyelids. The eruption 
generally begins to appear on the second day, pre- 
senting a florid aspect, and, with the exception of the 
peculiar roughness called goose-flesh, which frequent- 
ly attends upon it, it is not sensible to the touch. This 
enables us to distinguish it from measles, the rough- 
ness of w T hieh may be felt as well as seen. This 
eruption, like the others, begins with minute red 
points. These coalesce, and spread into broad patch- 
es, presenting a scarlet-colored surface with little in- 
terruption. It is preceded and accompanied by dry 



Lectures on Fever. 211 

skin, and hot evening exacerbations of fever. In 
many eases the glands about the throat are swollen, 
and tender to the touch. The different degrees of 
violence of this disease are indicated by the epithets 
simple, anginose, and malignant; but these distinc- 
tions are of little use in practice. 

It often happens that scarlet fever appears in so 
mild a form as to receive little or no medical treat- 
ment ; but although the constitutional disturbance 
is not great, and the anginose symptoms not urgent, 
it may happen that cerebral congestion or irritation 
comes slowly on, and we have unexpectedly to contend 
with coma and delirium, followed by great prostra- 
tion of fc vital power. And in the more open and 
active forms of the disease, when febrile excitement 
runs high, and requires active depletion and refrigera- 
tion, we are sometimes suddenly confronted with 
asthenic depression, which proves well-nigh uncon- 
trollable. On these accounts, scarlet fever should 
always be considered and treated as an insidious and 
dangerous disease, which may at any time assume a 
serious aspect. The eruption declines from the fifth 
to the ninth day, and the febrile excitement also, fol- 
lowed at a later period by more or less exfoliation of 
the cuticle. 

The graver forms of this disease require pretty 
active antiphlogistic treatment, and we must judge of 
the severity very much by the character of the pre- 



212 



Lectures on Fever. 



stage of in- 



vailing epidemic influence ; for it is difficult 
mine this by the symptoms in the ear 
dividual cases. Bloodletting is sometimes important, 
but, except in robust and plethoric subjects, it is bet- 
ter, in general, to be topical than general. Emetics 
are much to be relied upon, especially when the an- 
ginose symptoms are troublesome, as in other cases of 
inflammation of the throat. Cathartics must be used 
in moderation, but so as to rid the bowels, effectually, 
of all offending ingesta and morbid excretions. Ipecac, 
calomel, oil, and turpentine, are among the safest and 
the most efficient of these remedies. Bathing, too, is 
all-important, but the temperature of the bath must 
from time to time be carefully considered, substituting 
warm and even hot bathing for cold, in proportion to 
the abatement in febrile excitement, and in the tension 
of the pulse. Not urifrequently the patient requires 
cold applications to the head and throat, while hot 
water and sinapisms are used for the extremities. In 
this, as in the other eruptive fevers, I have found 
tepid sponging with water and vinegar, persistently 
applied over the whole surface, to be an effectual 
means of refrigeration ; but in the proper stage for 
its application the warm or hot bath is among the 
most valuable of all our remedies in the treatment of 
scarlet fever. 

The partial suspension of the functions of the skin 
is a prominent difficulty in all eruptive fevers, but 



Lectures on Fever. 213 

more in this than in any other form, excepting, per- 
haps, the confluent form of small-pox. It becomes 
an object, therefore, not only to restore these func- 
tions, but to excite the kidneys to increased action, 
that the patient may receive the benefit of their com- 
pensatory power. Various applications to the skin 
are advised by authors, but I doubt if any are more 
valuable than water, or a mixture of water and vin- 
egar. ]NTo doubt oleaginous substances are useful, but 
beside being dirty and troublesome they are, either in 
health or disease, only indifferent substitutes for wa- 
ter. To excite the kidneys to increased secretion, I 
have found the nitrous diuretics, with abundant dilu- 
tion, generally best ; but in some conditions the oil 
of turpentine is more efficient. We must consider, 
also, that the disease which is doing such injury to the 
skin extends to the mucous membrane of the mouth 
and throat, and even the stomach and bowels. On 
this account, also, the turpentine is a valuable reme- 
dy ; and so useful has it proved in some epidemics in 
England, that some physicians there have advised us 
to rely on it as our principal remedy, even from the 
beginning of the disease, and without reference to 
the extent of febrile excitement. For local applica- 
tion to the throat we may depend upon iodine, nitrate 
of silver, capsicum, and common salt. When one 
of these fails to give relief, another may be substi- 
tuted, and it will rarely be found that one or another 



214 Lectures on Fever. 

of them will not accomplish all that can be expected 
from a local remedy. In the asthenic stage ammonia 
becomes a valuable remedy, but good brandy is some- 
times even more effective, especially with children of 
nervous temperament. 

The sequelae of scarlatina are often more trouble- 
some than those of measles. Dropsy sometimes en- 
sues, with such sthenic symptoms as require depletion, 
even bloodletting, followed by mercurials, iodine, and 
various diaphoretic and diuretic remedies. When the 
sthenic condition has been so far subdued as to favor 
the r establishment of secretion and absorption, the 
dropsical fluid is, in general, more readily disposed of 
by cutaneous action, than by urinary secretion. Of 
course, we must not expect such relief while there ex- 
ists an excess of excitement, and we must be careful 
not to commit the mistake, too common in such cases, 
of using tonics when depletives are required. At 
the proper time for such influences, the apocynum 
cannabinum is one of the most efficient diaphoretic 
and diuretic remedies, and will sometimes relieve the 
dropsical affection more readily than any other. 

In exanthematous fevers there is more or less of 
disordered innervation, for the relief of which physi- 
cians are prone to prescribe opium in some form, and 
with good effect as far as concerns nervous excite- 
ment ; but the remedy is objectionable in most cases, 
on account of its deleterious influence over the enfee- 



Lectures on Fever. 215 

bled glandular action. It may generally be dispens- 
ed with, except in cases of considerable pulmonary 
irritation, when it should be used sparingly, and with 
distrust. And these remarks apply with even greater 
force to the sequelae, than to the active stage of the 
disease. One great difficulty in these sequelae is, the 
want of healthy action in considerable portions of the 
secernent system, and the tendency of opium is to 
increase it by inducing torpor. Aconite is an excel- 
lent substitute ; and it is, besides, our best arterial 
sedative. 

Great care should be taken of our patients during 
the period of desquamation. The healthy functions 
of the skin are slowly resumed, and the tender sur- 
face should be well protected against the influence of 
sudden changes of temperature. The uncomfortable 
rigidity of the skin may be ameliorated by the appli- 
cation of proof spirits holding a portion of glycerine 
in solution ; or by a solution of borax in water ; and 
in case of much itching of the skin, a small quantity 
of sulphate of morphia may be added to either of 
these solutions. But flannel covering for the body, 
both day and night, is all-important, as affording at 
once protection against cold, and facilities for the es- 
cape of perspirable matter. 



LECTUEE XIII. 

GENERAL REMARKS. 

Now that I have, in the twelve previous lectures, 
treated of fever in general, and of the various forms 
and grades which you are most likely to meet with in 
practice, I propose to make a few additional remarks in 
reference to the whole subject. This class of diseases 
will occupy your attention in practice more than all 
others, and in treating it, in all its various forms, you 
will have to contend with many anomalies and obscu- 
rities, which will often be very perplexing, and some- 
times, in spite of all your skill, lead to serious and 
fatal results. Although fever appears to be a distinct 
disease, and one which is well defined and described 
in the books, you will often have occasion to observe, 
that in this region of country it is liable to be compli- 
cated with other diseases, so as to require great dis- 
crimination in diagnosis and treatment. In spite of 
the simplicity of definitions, therefore, unless you are 
constantly on your guard in respect to peculiarities 
and complications, you will frequently meet with dis- 



Lectures on Fever. 217 

appointment, and goffer the evils of censure and 
chagrin. 

Especially is this true of the periodic movement, so 
common, so long known to the profession, and yet so 
mysterious and inexplicable. It is true now, as it 
was centuries ago, that we know nothing of the na- 
ture and cause of periodicity ; but we have the best 
reason to know that its influence is exerted over us in 
all places and at all seasons. In other countries it is 
said to be different, and in some it is supposed the 
agency has no existence. European writers lay little 
stress upon the subject, and I remember to have seen 
it stated by some medical lecturer in Boston, Massa- 
chusetts, that it was a subject of gratulation in that 
city and country, that periodic disease was wholly un- 
known there. Subsequently, however, it was an- 
nounced in a medical journal, that the people of Bos- 
tun had become alarmed by the report of certain physi- 
cians, that several cases of periodic fever had appear- 
ed in the neighborhood of that city. These were sup- 
posed to have been caused by vast deposits of earth 
in the work of filling up low, marshy grounds : which 
is confirmatory of observations in this country in re- 
gard to such influences. 

In reading the descriptions given of certain diseases 
in the Northern States and in Europe, and of the suc- 
cessful use of antiperiodic remedies in their treatment, 
it is not easy to forego the suspicion that periodicity 
10 



218 



lectures on Fever. 



really does prevail in those countries to a greater ex- 
tent than is generally believed. Be this as it may, 
we have to deal with the important fact, that in all 
the South, periodic diseases are always prevailing ; 
but in some places and seasons they are more active 
than in others. Impressed as we all are with this 
great truth, it is but the part of common prudence to 
exercise constant vigilance for the detection of these 
influences. Such vigilance often reveals the fact, that 
nearly every form of disease which we are called upon 
to treat may be complicated with this difficulty, 
either as a primary or secondary affection ; and more 
or less seriously according to season, locality, and epi- 
demic influence. Frequently the periodic action is 
very obscure ; but in numerous cases of disease pre- 
senting anomalous symptoms we are enabled, by skil- 
ful scrutiny, either to trace them to this cause, or to 
detect, in connection with them, this complication. 
Indeed, we are not unfrequently forced to the conclu- 
sion, that periodic influence lies at the foundation of 
certain diseased conditions, when the patient enter- 
tains the least possible suspicion of the fact. The 
signiticancy of these remarks will be better understood 
when I shall have directed your attention to particular 
affections, which are of obscure paroxysmal character. 
Infantile diarrhea, and kindred diseases affecting 
the digestive organs of children, hold a prominent 
place in the list of these affections. And there are 



Lectures on Fever. 219 

few facts in connection with our profession which are 
of a more melancholy character than the loss of life 
from this class of diseases. It appears, indeed, to 
contravene, to some extent, the designs of Providence 
in peopling the earth, that so large a portion of mor- 
tality from disease should occur among those of a tender 
age. Children born into the world without the least 
perceptible taint of hereditary disease, and in the pos- 
session of every promise of robust and permanent 
health, become diseased in their digestive organs, in 
such manner that no medical treatment, however suc- 
cessful in its temporary effects, can be depended upon 
to eradicate it. They linger on from week to week, 
and from month to month, under the delusive hope 
inspired by what seems to be skilful treatment, until, 
from emaciation, inanition, and sometimes ulceration 
of the mucous tissues, they sink into untimely graves. 
Every thing has been done for them, perhaps, which 
ingenuity, skill, and affection could supply, excepting 
only the one thing indispensable to recovery — some 
remedy for periodicity. It is quite natural for the in- 
experienced to suppose that this evil might be discov- 
ered by the physician, the parents or the nurses ; but 
I assure you that in many cases it is no easy matter. 
The periodic movement is exceedingly obscure ; and 
even after the suspicions of the physician are fully 
aroused, he may find it impossible to satisfy himself, 
without observing the effects of antiperiodic remedies. 



220 



Lectures on Fever. 



He must adopt the experimental use of them, or con- 
tinue to risk the chances of failure. I have reason to 
believe, that for the want of such experiment, care- 
fully made, the lives of many children are sacrificed, 
especially in towns and cities. These views receive 
confirmation from the relief often obtained by remov- 
ing patients to districts less infested by periodic influ- 
ences.* 

Neuralgia is another disease very frequently com- 
plicated with obscure periodicity. Indeed, it is gen- 
erally, as it appears in the South, a periodic disease, 
exhibiting, but often in a hidden or masked manner, 
regular paroxysms, in the form of quotidian, tertian, 
or double tertian fever, with periods of intense pain 
marking each exacerbation. The first stage is either 
one of cold sensations, or exhibiting enough of the 
usual symptoms of a chill to admonish the patient of 
the approaching attack. The next is a stage of ex- 
citement, with accelerated pulse and severe suffering, 
the greatest pain in many cases being felt in the 
course of some branch of the facial nerves. All parts 
of the system are liable to suffer, and the seat of pain 
is frequently changed without apparent cause ; but 
the jaws, scalp, some part of the orbit of the eye, and 



* When these remarks were written, they had reference only to 
Southern diseases ; but from the observations of a year's practice in New- 
York City, I am inclined to the opinion, that they are equally applica- 
ble here, where nothing is so much wanted as remedies for disease. 



Lectures on Fever. 221 

even the eye itself, the internal ear, etc., are favorite 
seats of the local pain, which is frequently attended 
by swelling. Fatal cases are not common ; but the 
disease is exceedingly painful, persistent, and difficult 
of cure. When once relieved, we have much reason 
to fear a relapse, and that the disease may continue 
to recur for months, and even for years. 

In the treatment of this disease quinia is nearly 
always useful, and it sometimes affords very prompt 
and permanent relief ; but more frequently the disease 
will return, and return repeatedly, often observing 
septenary periods, and the salts of quinia seem nearly 
to lose their effect upon it. In such cases I have 
found arsenic the best substitute, or arsenic and 
quinia given in conjunction. For such purpose I 
prefer the pure arsenous acid, as more efficacious than 
the arsenite of potassa. But in the treatment of this 
disease, physicians nearly always resort to the use of 
narcotic remedies, the most prominent of which is 
opium, and generally in the form of Dover's powder. 
I have found stramonium the more efficient remedy 
in all neuralgic affections, but in none are its effects 
more striking than in those of the uterus. As an ex- 
ternal remedy, the saturated tincture of aconite is 
generally to be preferred over all others, and especi- 
ally in uterine affections. But often the chloroform 
liniment affords much relief, as does also the vera- 
trine ointment. 



222 Lectures on Fever. 

Bheumatism is another disease — if indeed it be an- 
other — which is very commonly obscurely complicat- 
ed with the periodic movement. This becomes very 
painful in the joints and limbs, and sometimes in the 
stomach and bowels. The heart, which European 
physicians require to be guarded and watched with 
peculiar care, rarely becomes seriously affected in this 
country. Perhaps one reason is, that the disease in 
this country is periodic, and generally treated as such ; 
while in Europe it may more commonly exist as a 
local affection, giving rise to symptomatic fever, and 
a fatal issue depend upon metastasis. Fatal cases 
among us are not very common ; but the disease is 
often painful, persistent, and difficult of cure. When 
once relieved we have always much reason to fear a 
relapse, and that it may continue to recur for months 
and years. When complicated with periodicity, the 
treatment is the same as in neuralgia. Besides anti- 
periodics, I have found no remedy to be so uniformly 
beneficial as stramonium ; but a necessity always ex- 
ists for attention to the condition of the digestive or- 
gans, and generally these are best regulated by small 
doses of calomel. 

Dysentery often perplexes us with its febrile com- 
plications, and especially when it appears as an epide- 
mic. In such case it nearly always requires the anti- 
periodic treatment. Without due attention to this 
matter, we are likely to suffer disappointment in our 



Lectures on Fever. 223 

best efforts to effect a cure of the disease. In the 
period of apyrexia the usual remedies for dysentery 
may give such relief as to fill us with hopes of a fa- 
vorable result ; but when the febrile paroxysm re- 
turns, and especially in the stage of exacerbation, the 
dysenteric symptoms are certain to recur, and the fre- 
quent repetition of this course causes rapid emaciation 
and loss of strength, until the patient finally succumbs 
to an insidious and destructive disease, in which a 
mysterious complication has been overlooked. In 
some of these cases the dysenteric affection becomes 
chronic, and the sufferings of the patient are indefin- 
itely prolonged, with a manifest increase of them at 
septenary periods. Hence the necessity for watching 
the phenomena attendant upon this disease very 
closely, and especially when it prevails as an epidemic 
in malarial districts. Dysentery may justly be ranked 
among the most obstinate and unmanageable of our 
diseases, even thougli it exist without this periodic 
complication ; but whenever this difficulty does occur, 
it is not easily cured without addressing our remedial 
measures, in great part, to the relief of the periodic 
movement. 

Ophthalmia, too, although it may seem, upon a 
superficial examination, to be a disease of a strictly 
local character, is, in this country, frequently involved 
in the periodic movement, and to such an extent as 
to render it incurable, except by resorting to the ap- 



224 Lectures on Fever. 

propriate constitutional treatment. And I very much 
doubt whether there is any other local disease which 
proves more intractable under like circumstances. 
You will do well, therefore, in all cases of great ob- 
stinacy, to examine into this matter, and even to try 
the effect of the antiperiodic treatment, whenever the 
mysterious movement proves to be too obscure to 
be detected by observation. Tou will find, not un- 
frequently, that it is only by such experiment that the 
existence or non-existence of periodicity can be deter- 
mined. Especially is such experiment advisable in 
strumous habits, which seem to favor the most obsti- 
nate ophthalmic inflammation. It is, perhaps,' on 
account of its peculiar influence over the circulation in 
the conjunctivae and the eyelids, that arsenic frequently 
proves more efficacious in this disease than quinia. 
The excessive pain and intolerance of light are dimin- 
ished by the exhibition of morphia ; but on account 
of its injurious influence over the digestive function, 
I have generally given preference to stramonium and 
belladonna. The former is better suited to the alle- 
viation of pain, and the latter to the relief of pho- 
tophobia. 

Chorea may justly be considered one of the oppro- 
hria of our profession, and principally, I believe, be- 
cause of its undiscovered periodic character. It is 
one of those diseases which physicians have believed 
would run its course in spite of all medication. Some- 



Lectures on Fever. 225 

times the disease recurs annually for several years in 
succession, and finally disappears only upon the pa- 
tient's coming to years of maturity, for the disease gen- 
erally attacks young subjects. In the English hospi- 
tals great reliance is placed upon arsenic as a remedy ; 
but I do not know that physicians there attribute its 
curative power to its antiperiodic effects, or that they 
acknowledge the existence of the periodic complica- 
tion. But in this country, where arsenic is also used 
successfully, it may be considered curative by virtue 
of this quality, because quinia is our next most effica- 
cious remedy. The disease, however, if closely ob- 
served, affords sufficient evidence of its periodic char- 
acter. I had an interesting case of this disease, which, 
in one of its annual returns, became complicated with 
scarlatina of a violent grade, attended not only by an 
increase in the severity of the chorea, but also by a 
more distinctly marked periodicity. There was at no 
time during the progress of the scarlatina any sign of 
an abatement in the force of one disease to favor the 
course of the other ; and when the scarlatina had run 
its usual course and subsided, the chorea remained 
unchanged and unabated. The prevailing opinion, 
that when two diseases attack the same subject, one 
must give way to the other to some extent, was not 
confirmed in this instance. 

Chorea has sometimes been supposed to arise from 
disordered secretions in the digestive organs, which, 
10* 



226 Lectures on Fever. 

in most cases, are found to exist ; but it is doubtful 
whether as cause or effect. Frequently it is the case, 
that the first noticeable symptom of an approaching 
attack is, a morbid and somewhat excessive secretion 
of saliva, attended by loss of appetite and disagree- 
able taste. The first muscular contractions are also 
observed in distortions of the mouth, and they are 
generally coincident with this unhealthy secretion of 
saliva. In such cases I have found strychnia to be a 
valuable remedy. Indeed, in all stages of the disease 
it is useful, and sometimes the disease subsides under 
its influence; but in general it is better to conjoin 
with it the antiperiodic treatment. 

The better to enable you to appreciate the import- 
ance of exercising constant scrutiny for the mysteri- 
ous morbid movement called periodicity, I have now 
invited your attention to the consideration of a few 
diseases most likely to exist with such complication ; 
but there are others to which time will not permit me 
to refer in detail. Indeed, such is the extent to which 
periodic influences prevail in this country, that it is 
scarcely safe at any season of the year, in any pro- 
tracted case of disease, to assume the fact of their non- 
existence. If the patient is not subject to this influ- 
ence from the beginning, he is very likely to become 
so during the progress of his disease ; and this is true 
of local as well as general diseases, and even of 
wounds and injuries. Experience teaches us these 






Lectures on Fever. 227 

truths ; and if you inquire into the practice of physi- 
cians engaged in extensive and successful business, 
you will find them administering antiperiodic reme- 
dies almost habitually in the treatment of diseases 
which in themselves bear no necessary relation to pe- 
riodic fever ; and when such cases fall into the hands 
of strangers to our Southern diseases, their want of 
success but too plainly shows their inability, for want 
of experience, to appreciate the considerations which 
I am now urging upon your attention. Hence the 
justness of the remark so often made by Southern 
physicians, that men who have been educated in 
Northern schools, or engaged in Northern practice, 
must learn the peculiarities of Southern diseases be- 
fore they can become successful practitioners in the 
South. Unfortunately, they seldom come to us in a 
teachable mood, and only improve upon their own 
experience. 

Sometimes you will find that physicians, in availing 
themselves of the benefits of quinia in anomalous 
cases of disease, assign its efficiency to the tonic pow- 
er it is supposed to possess. But the effects which 
lead to this conclusion would just as much justify us 
in attributing tonic power to the preparations of mer- 
cury. In both cases it consists, in my opinion, in the 
removal of disease, and enabling the patient to expe- 
rience the beneficial influences of returning health. 
The Peruvian bark doubtless does exercise tonic pow- 



228 Lectures on Fever. 

er, by virtue of its astringent and bitter tonic quali- 
ties ; but we have no reason to believe that these ex- 
ist, to much extent, in its proximate principle, quinia, 
or in any of its salts. 

You will meet with many persons, especially in the 
so-called malarial districts, who have been treated 
with quinia in large doses, until, as they will tell you, it 
has lost its remedial effect upon them, while it causes 
distressing disturbance of the functions of the brain 
and nervous system. These representations are not 
to be disregarded, for it is doubtless true of quinia 
that when persons, especially those of a nervous tem- 
perament, have been frequently subjected to its full 
constitutional action, they ever afterward suffer from 
its painful or toxical, without receiving the proper 
benefits from its remedial, effects. There is an idio- 
syncrasy too with some, which subjects them to the 
evil influences of quinia from the beginning. Some- 
times this appears in its action upon the nervous sys- 
tem alone, and sometimes upon certain secretions, es- 
pecially of the kidneys. For all such you must find 
some substitute for the quinia ; and, according to my 
experience, the best of these is arsenic, which is an 
antiperiodic remedy scarcely less active and efficient 
than quinia, and one which seems to be peculiarly 
well suited to such cases. 

Arsenic must be administered, however, very cau- 
tiously, and its long continuance at any one time 



Lectures on Fever. 229 

should generally be avoided, especially if given in 
full doses, and frequently repeated ; and for the rea- 
son not only of its toxical effects, but because persons 
experiencing its remarkable tonic power are sometimes 
tempted to its habitual use. Its effects are to en- 
hance the vigor and activity of the muscular system. 
and to invigorate the respiratory and vocal organs ; 
increasing, indeed, to a remarkable degree, the pow- 
ers of bodilv action and endurance, and guarding the 
system against fatigue. Of course, the habitual use 
of arsenic must cause proportionate exhaustion, and 
tend to wear away, prematurely, the physical ener- 
gies. It has been contended that the continued use 
of arsenic may produce dropsical affections, evidenced 
in the first instance by an edematous appearance of 
the eyelids and face. This appearance is not uncom- 
mon, but I have never witnessed any further sign of 
dropsical affection from its use. It is supposed to be 
a sign of the mil constitutional effect of the remedy ; 
but an earlier and more reliable indication of this is 
the appearance of slight inflammation of the con- 
junctiva?, with more or less itching or pain, and intol- 
erance of light, as in other cases of incipient ophthal- 
mia. 

One other remark in reference to the action of qui- 
nia and arsenic, whether given separately or conjoint- 
ly. You will often have occasion to observe, that 
when your patient is laboring under the influence of 



230 Lectures on Fever. 

periodicity, he will bear them better, and in larger 
doses, than when he is not. A moderate dose of 
either or both will frequently cause a disagreeable 
sensation in the head, with more or less headache, in 
the healthy subject ; when the same person laboring 
under the influence of periodic disease would expe- 
rience only comfort and relief from the same doses. 
In any experiments which you may feel called upon 
to make, with a view to determine the existence or 
non-existence of periodicity in any case, it will be 
well to bear in mind this important fact. Much of 
the prejudice against these remedies, growing out of 
the disagreeable effects they sometimes produce, arises 
from the fact of their being used when they are not 
needed — when there is no periodicity existing. 

And now I wish to call your attention to the use 
of chloroform as an internal remedy, in the class of 
diseases which we have been considering. We hear 
much of its value as an anaesthetic when inhaled into 
the lungs, but physicians do not seem to be fully 
aware of its powder over disordered innervation when 
taken into the stomach. The occasions most requir- 
ing its use in this way are for the relief of congestions 
in the cold stage of fever, which in adults cause great 
distress in the thoracic and abdominal viscera, and 
sometimes in the brain ; and in children frequently 
produce convulsions. In congestions of the brain 
from sunstroke, concussion, parturition, etc., and in 



Lectures on Fever. 231 

spasmodic asthma and colic, chloroform is eminently 
useful. In cases of urgency, I suppose a fluidrachm 
may be considered a medium dose, and it may be re- 
peated as occasion requires. In no other diseased 
condition have I found this remedy to be so valuable 
as in infantile convulsions. In these, and in some 
cases of adult disease, I have administered the rem- 
edy by enema as well as by the mouth. It is an im- 
portant fact for you to know, too, that when your pa- 
tient is in a state of insensibility, or convulsed, so 
that other remedies cannot be given by the mouth, 
chloroform poured between the lips, and suffered to 
trickle through the teeth, will, when it reaches the 
organs of deglutition, excite them to action, and be 
carried into the stomach, almost while any vitality 



* Cases in Illustration. — 1. In 1852, a stout, plethoric man was 
found lying in the street in a state of insensibility, supposed to be 
from sun-stroke. The bystanders declared him unable to swallow 
water. I poured into his mouth from a vial, a drachm or more of pure 
chloroform, which he soon swallowed, and in less than half an hour he 
was quite relieved. 2. The same year a child, aged three years, had 
been for more than one hour in a general convulsion. A small tea- 
spoonful pure chloroform poured into the clenched jaws percolated 
through the teeth, and found its way to the stomach. In a few min- 
utes the spasms ceased, and after sleeping quietly for half an hour, the 

child awoke, and called for food. 3. In 1854, Mr. was seized 

with a severe chill. I found him covered with blankets, and surround- 
ed by hot bricks, drinking hot brandy toddy. A full tea-spoonful pure 
chloroform was immediately given, and all the hot applications removed. 



232 Lectures on Fever. 

Change of habitation and locality is no mean rem- 
edy for periodic diseases, frequently enabling us to 
effect a cure more promptly and effectually. Inter- 
mittents of a persistent and obstinate character fre- 
quently subside upon removal of the patient from the 
city to the country, and the reverse ; and especially 
upon emigrating to a different country and climate. 
Children suffering from intermittent diarrhea often 
find relief from being moved from one neighborhood 
to another in the country, or even from one street to 

The chill at once subsided, and only slight febrile reaction followed. 4. 
In 1863, a child of C. C. C, aged about two years, was taken with a con- 
vulsion, which continued in spite of remedies nearly two hours. I found 
it inhaling chloroform without effect. A full tea-spoonful was at once 
introduced into the stomach, and a like quantity soon after given by 
enema. In half an hour the child was in a sound sleep, and recovered 
without difficulty. 5. In March, 1865, a gentleman in New-York City 
had been suffering with a severe chill for more than one hour. I gave 
him a tea-spoonful chloroform in sweetened water, and partial relief 
only being obtained, the dose was in half an hour repeated. The chill 
soon subsided, and only moderate reaction followed. 6. On the sev- 
enteenth April, 1865, a child, five and a half years old, was seized with 
a convulsion at the corner of Sixth Avenue and Twenty-seventh street. 
She was taken thence to Leroy street, and after nearly two hours of 
uninterrupted convulsion took a full tea-spoonful pure choroform. In 
half an hour the convulsion had ceased, and she was in a quiet sleep, 
and recovered. 

On the thirty-fifth day afterward, at the same hour, this child had an- 
other attack of the same kind. The convulsions had continued exactly 
two hours, when a tea-spoonful of chloroform was given ; this was fol- 
lowed in twelve minutes by half as much more, giving entire relief. 



Lectures on Fever. 233 

another in the city. TThen yellow fever prevails as 
an epidemic, I have never known a patient to be 
moved into other quarters before the fatal symptoms 
appear, without producing a good effect ; and some- 
times when conveyed beyond the infected district, a 
decided intermission of the disease is produced, af- 
fording great advantages in the treatment. Perhaps 
the good influences may be partly due to the gentle 
motion and jarring of the mode of conveyance ; but 
whatever may be the cause, the beneficial effects are 
remarkable, and I have thought it possible that the 
time might come when physicians will employ the 
rail-car as an important remedial agency. It is to be 
considered, too, that certain forms of disease are often 
mysteriously epidemic in a single habitation or fam- 
ily, insomuch that every person in the household suf- 
fers an attack, and relapses continue among them 
during a whole season, unless removed. In no other 
disease, perhaps, is this more strikingly and uniformly 
true than in diphtheria, which rarely ever attacks one 
child in a family without extending to all the rest, 
and sometimes even to the adult members. And you 
will have occasion to observe the very common fact, 
that diseases epidemic among negro slaves are fre- 
quently confined to a single plantation, and even to a 
single house. The importance of change of locality 
in all cases of limited epidemics can scarcely be over- 
estimated. 



234 Lectures on JBever. 

In conclusion, I may caution you, as I have often 
before done in my lectures, against excessive, incon- 
sistent, and complicate medication. It is a common 
fault of young physicians to indulge in over-dosing, 
and in the use of a multiplicity of remedies* This 
arises in a measure from uncertainty in diagnosis, and 
undue confidence in certain medicines. The first ob- 
ject in every case of disease is to ascertain what are 
the true indications ; and the second, to answer these 
with the simplest and most efficient means. Not to 
observe these rules is to prescribe very much at ran- 
dom. If you are quite certain In your diagnosis, the 
proper remedy suggests itself ; and in using it care 
must be taken to give it in proper quantity, and not 
to impair its efficacy by inconsistent and incompati- 
ble combinations. It will readily occur to you when 
you find the secretions, especially of the digestive or- 
gans, checked or suspended by fever, and while con- 
stitutional excitement has been suitably subdued, that 
calomel is, in general, strongly indicated ; the effect 
of which is to restore these secretions. But if you 
combine opium with the calomel, the tendency of 
which is to suspend these secretions, you may expect 
disappointment in the amount of your success. In 
such cases the two remedies do not agree well toge- 
ther ; and in the graver forms of fever the use of opi- 
ates in such condition of the secerning system, will 
not unfrequently cause fatal results. I mention this 



Lectures on Fever. 235 

by way of illustration. But there are other incon- 
sistencies too commonly practised, such as combining 
specific and topical emetic medicines, which operate 
at entirely different intervals of time ; also quick and 
slow-moving cathartics. Certain medicines, however, 
have their valuable adjuvants, suited to particular 
cases and conditions ; but in a large majority of dis- 
eases which we are called upon to treat, if we know 
the proper remedy to meet existing indications, we 
shall do better to give it by itself. It is a conveni- 
ence in many cases, therefore, to hold each remedy 
separate, rather than compound them in complicated 
formulas. Even the vehicle is carefully to be consid- 
ered, because nothing is more certain than that no 
article of diet, however bland, can pass through the 
bowels of a sick person undigested, without injurious 
effects. Even mucilaginous drinks cannot be thus 
trusted. 




■ raw 






